Concordant Group

5958 Priestly Drive

Carlsbad, CA 92011

Concordant Group 2014 Benefit Enrollment / Confirmation /

Change Form

Step 1 Complete the form

• Fully confirm and/or complete pages 2-3 of this document:
• Read, sign and date.
• If you have more dependents or beneficiaries than form space allows, attach an additional page.
• Incomplete submissions may delay processing and result in retroactive premium deductions.

Step 2 Submit the form

• Sign and date this form. Return to [HR] at [office] or email to [Email] within 10 days of the
[EffectiveDate]
• Retain a copy for your records.
• Submit the completed, signed form and required documentation by one of the following
methods:
1. Email
HR@concordantgroup.com
2. Fax
Confidential Benefits E-fax: 480.993.0007
3. Hand-deliver:
Concordant Group
Attn: Steve Gin
5958 Priestly Drive
Carlsbad, CA 92011
4. Mail:
Concordant Group
5958 Priestly Drive
Carlsbad, CA 92011

Step 3 Verify your coverage

You will receive a confirmation notice within 48 hours of receipt of your enrollment form. You can also
verify your information at www.concordantgroup.com.
 Concordant Group
5958 Priestly Drive
Carlsbad, CA 92011

Employee Identification Information:

First Name: Last Name: Middle Initial:

Address: Apartment / Suite:

City: State: Zip:

Social Security Number: Gender:

Male Female
Employee Number:

Office:

Job Title:

Information Looks Good!

My employee information has changed

Medical Plan Choices:

HealthShield PPO
Employee only $52.00
You & 1 child $142.00
Employee & Spouse / Domestic Partner $206.00
Family $275.00

HealthShield HMO
Employee only $22.00
Employee & 1 child $112.00
Employee & Spouse / Domestic Partner $176.00
Family $245.00

No Coverage
 Concordant Group
5958 Priestly Drive
Carlsbad, CA 92011

Dental Plan Choices:

Employee only $8.55

Employee & 1 child $14.00
Employee & Spouse / Domestic Partner $14.00
Family $20.00
No Coverage $0.00

Vision Plan Choices:

Employee only $3.00

Family $7.00

Reimbursement Account Choices:

Health Care Account

No Account $3.00
Set account $7.00

Long Term Disability (LTD) Choices:

LTD coverage is mandatory. The firm reimburses you in your pay for the cost of this benefit. You choose
whether you want your cost paid with before-tax or after-tax dollars; there are tax ramifications to your
choice. If you make no election, your election will automatically default to the after-tax option.

Before-tax
Set account

Basic Life Choices:

The firm automatically provides you with Basic Life Insurance in the amount of 1.5 times your annual
salary at no cost to you. Remember to designate a beneficiary for this insurance. Beneficiary
designation forms are available on www.concordantgroup.com.
 Concordant Group
5958 Priestly Drive
Carlsbad, CA 92011

Your Agreement:

• I Understand my Medical, Dental and Vision options.

• I understand my Reimbursement Account, LTD, and Life Insurance options, and I am enrolling
for the converges shown on this form.
• I direct the firm to adjust my pay for any required contributions either on a before-tax (salary
reduction) or after-tax basis, as applicable.
• I understand that my elections will stay in effect for the remainder of the calendar year unless I
have Qualifying Life Events as defined by Federal regulations.

Your Signature: Date: