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Group Enrollment Processing
In order to ensure proper processing of your applications, please read the following instructions carefully.
1) Once you have selected the plan(s) in which you wish to enroll, print and complete thecorresponding application(s).
2) Make sure you have signed and completed the application(s) in their entirety. Check them forany errors or missing information.
3) Review, complete and sign the Automatic Deduction Agreement form.
4) Make a photocopy of your voided check for the account from which you would like the premiumdeduction to take place and include it with your forms. Remember, all bank account deductionswill take place on the 1st business day of each month. If we are unable to draft your account onthis day, you may be subject to fees as outlined in the Automatic Deduction Agreement.
5) Email your application with the Automatic Deduction Agreement and the voided check [email protected]. We MUST have all applications by the posted due date orcoverage cannot become effective!
Please call us with any questions you have during the enrollment process.
Group InsuranceBenefi ts Administrator
P: (888) 564-0300, toll freeF: (856) 396-3193E: [email protected]
DergalisASSOCIATES
Email all finished paperwork to: [email protected]
Q: Must I take all of the benefits? A: No, each benefit can be purchased individually.
Q: Will I get another oppor tunity to enroll if I decline to take coverage now? A: Once a year, the Group Dental and Vision plans will have an Open Enrollment period. However, the Group
Disability and Life Insurance will NEVER be offered again on a Guaranteed-Issue basis. While you can apply at a later date, limited medical underwriting will be required and the carrier will have the right to decline you coverage based on the results.
Q: I currently have other coverage for Dental and Vision. If I lose that coverage, could I participate in your program?
A: Yes, you will have the oppor tunity to enroll in the Dental or Vision plan within 30 days of a qualifying life event such as birth, death, divorce or loss of coverage. For more information on what constitutes a qualifying life event, please contact our office.
Q: Is the Automatic Deduction from my checking account the only way to pay? A: Please contact our office at (888) 564-0300 for more information. Additionally, you can use a savings account
as long as you provide a deposit slip imprinted with your name, bank account number and bank routing number. Please note, we are not set up for individual billing and cannot accept a check as payment.
Q: When and how will I receive confirmation of my coverage? A: You should receive an email from our office within three weeks. Please make sure to check your junk mail
folder if you haven’t received the email.
Q: What if I have an emergency before I receive proof of coverage?A: In the event of an emergency situation, you should contact
Someone will help in the transition period.
Q: Why am I not receiving email communication from the group insurance
A: The domain agentbenefits.net may be filtered out by some e-mail providers as “SPAM”. Please ensure to update your email address and communication preferences.
Frequently Asked Questions
Group Insurance at (888) 564-0300.
department?
Vision Insurance InformationMeybohm Real Estate
vision.
PPO Networkwww.metlife.com/vision Group # 160667
Agent & Spouse ylnO tnegA Agent & Child Agent & Children Family $7.80 $15.64 $13.24
Monthly Rates Effective until 5/1/2019 to 12/31/2020
There are thousands of general dentists and specialists to choose from nationwide — so you are sure to find one who meets your needs. You can receive a list of these participating vision online at www.metlife.com/vision or by calling 1-800-942-0854 to have a list faxed or mailed to you.
$21.83 $13.24
DergalisASSOCIA TES
HOME ADDRESS
SS #
FIRST
COMPANY NAME OFFICE LOCATION
DENTAL VISION
A. PLEASE CHECK ALL COVERAGE(S) YOU ARE APPLYING FOR
PHONE
CITY
I represent that all information supplied in the application is true and correct. Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act which is a crime.
STATE
BIRTH DATE
HIRE DATE
GENDER
ZIP
M F
ADMINISTRATIVE USE ONLY
EFFECTIVE DATE
Applying for single coverage for myself Applying for myself and dependents listed below
B. PLEASE INDICATE WHO WILL BE INSURED UNDER THE POLICY (CHECK ONLY ONE)
SPOUSECoverage for:
Dental Vision Both
CHILD 1Coverage for:
Dental Vision Both
CHILD 2Coverage for:
Dental Vision Both
CHILD 3Coverage for:
Dental Vision Both
C. ENROLLMENT INFORMATION (COMPLETE IF INCLUDING COVERAGE FOR DEPENDENTS)
GENDER
GENDER
GENDER
GENDER
FIRST
SS#
SS#
SS#
SS#
BIRTH DATE
BIRTH DATE
BIRTH DATE
BIRTH DATE
SIGNATURE DATE
M F
M F
M F
M F
Dental and Vision Insurance Enrollment Form
OCCUPATION
Page 1 of 3
SIGNATURE REQUIRED
MI
MI LAST NAME
DEPENDENT RELATIONSHIP TO EMPLOYEE
DEPENDENT RELATIONSHIP TO EMPLOYEE
DEPENDENT RELATIONSHIP TO EMPLOYEE
DEPENDENT RELATIONSHIP TO EMPLOYEE
LAST
FIRST MI LAST NAME
FIRST MI LAST NAME
FIRST MI LAST NAME
RealtorMeybohm Real Estate
SIGNATURE of account owner*
*Note: Signature should be that of the owner of the checking account whose name appears on the check used for deductions.
SIGNATURE of insured
Revised 6/05/2015
DATE
DATE
Automatic Deduction and Notification AgreementPLEASE READ CAREFULLY. BY SIGNING BELOW, YOU AGREE TO HAVING READ AND UNDERSTOOD THE FOLLOWING:
I hereby authorize Realty Benefit Services, an affiliate of Dergalis Associates , to access my account for the SXUSRVH�RI�SD\LQJ�SUHPLXPV�IRU�WKH�LQVXUDQFH�EHQHÀWV�WKDW�,�VHOHFW��7KH�GHGXFWLRQV�FRXOG�LQFOXGH�KHDOWK��GHQWDO��YLVLRQ��OLIH��DQG���RU�GLVDELOLW\�LQVXUDQFH�SUHPLXPV��,�XQGHUVWDQG�WKDW�WKHVH�GHGXFWLRQV�ZLOO�EH�PDGH�SHULRGLFDOO\�DQG�,�UHDOL]H�WKDW�FKDQJHV�LQ�SUHPLXPV�PD\�UHVXOW�LQ�KLJKHU�RU�ORZHU�GHGXFWLRQV��,�IXUWKHU�XQGHUVWDQG�WKDW�,�VKDOO�LQFXU�DGGLWLRQDO�FKDUJHV�LQ�WKH�HYHQW�WKLV�GHELW�LV�UHWXUQHG�IRU�DQ\�UHDVRQ��,Q�WKH�HYHQW�WKDW�Realty Benefits Services�LV�XQDEOH�WR�FROOHFW�P\�SUHPLXPV�RQ�WKH�ÀUVW�EXVLQHVV�GD\�RI�WKH�PRQWK��,�ZLOO�EH�FKDUJHG����������,�XQGHUVWDQG�WKHUH�LV�QR�PRQWKO\�SDSHU�ELOOLQJ�IURP��Realty Benefit Services, an affiliate of Dergalis Associates �DQG�,�FDQQRW�SD\�E\�FKHFN������
SOCIAL SECURITY # EMAIL
HOME PHONE
HOME ADDRESSCITY STATE ZIP
CELL PHONE
REALTY COMPANY OFFICE LOCATION
Notifications,�DJUHH�WR�SURYLGH�VLJQHG�ZULWWHQ�QRWLFH�DW�OHDVW�WZR�ZHHNV�LQ�DGYDQFH�LQ�WKH�HYHQW�,�ZLVK�WR�FDQFHO�� FKDQJH�RU�DPHQG�P\�FXUUHQW�SROLFLHV���,�IXUWKHU�DJUHH�WR�LQGHPQLI\�DQG�KROG�KDUPOHVV�Realty Benefit Services, an affiliate of Dergalis Associates ��IRU�FKDUJHV�DVVHVVHG�RQ�P\�DFFRXQW�IURP�P\�OHQGLQJ� LQVWLWXWLRQ�GXH�WR�GHELWV�IRU�VHUYLFHV�UHQGHUHG���,�DJUHH�WR�QRWLI\�Realty Benefit Services, an affiliate of Dergalis Associates ��LQ�ZULWLQJ�RI�DQ\�FKDQJHV�WR�P\�EDQN�DFFRXQW���7KLV�QRWLFH�ZLOO�EH�DW�OHDVW�WZR� ZHHNV�LQ�DGYDQFH�RI�DQ\�VFKHGXOHG�SD\PHQW�GHELWV���You can email your notice to Dergalis Associates at [email protected]. )
,�XQGHUVWDQG�WKDW�WKHVH�VHUYLFHV�DUH�EHLQJ�SURYLGHG�VROHO\�WKURXJK�DUUDQJHPHQWV�ZLWK�Realty Benefit Services, an affiliate of Dergalis Associates��P\�UHDO�HVWDWH�ÀUP�DQG�WKH�LQVXUDQFH�FDUULHU��,�DP�DZDUH� that I must notify Dergalis Associates�LQ�ZULWLQJ�LI�,�QR�ORQJHU�ZRUN�DV�D�OLFHQVHG�5HDOWRU�RU�EHFRPH�D� UHIHUUDO�UHDOWRU�ZLWK�P\�FXUUHQW�5HDO�(VWDWH�ÀUP��7KLV�QRWLÀFDWLRQ�LV�P\�UHVSRQVLELOLW\��,I�,�GR�127�notify Dergalis Associates �ZLWKLQ����GD\V�RI�P\�WHUPLQDWLRQ��,�UHDOL]H�,�PD\�FRQWLQXH�WR�JHW�ELOOHG�IRU� VHUYLFHV�DQG�EHQHÀWV�WKDW�,�DP�QR�ORQJHU�HOLJLEOH�WR�UHFHLYH�DQG�,�PD\�IRUIHLW�DQ\�EHQHÀWV�UHFHLYHG�RU� SUHPLXPV�,�SDLG�IRU�WKHVH�EHQHÀWV�EH\RQG�P\�WHUPLQDWLRQ�GDWH��NO REFUNDS WILL BE PROVIDED FOR MY FAILURE TO NOTIFY DERGALIS ASSOCIATES OF TERMINATION OR SEPARATION FROM MY REAL ESTATE COMPANY�� ,�XQGHUVWDQG�WKDW�DQ\�FKDQJHV�WR�RU�WHUPLQDWLRQ�RI�P\�FRYHUDJH�ZLOO�DOVR�DIIHFW�WKH�FRYHUDJH�,�KDYH� HOHFWHG�IRU�P\�GHSHQGHQWV�
By signing, I acknowledge that I have read and accept the terms of the above notification agreement.
NAME OF INSURED
WERE YOU HELPED BY A DERGALIS REPRESENTATIVE? (please check) � YES � NO
IF YES, WHO:
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Attach Voided Check
Attach Your Business Card
DergalisASSOCIATES
Page 3 of 3
