D/V Technologies

Contact D/V
Email: gregg-r@dv-tech.com
Telephone: (800) 837-7105 ext. 128
Fax: (734) 996-1426
1935 Pauline Blvd. Suite 300
Ann Arbor, MI 48103

Enrollment Information

For yourself and each of your dependents, enter a name, Social Security number, and birth date.
NOTE: You may only cover legally married spouses, and children to age 19 or to age 25 if full-time student.

Dependent No. Name SS# Birthdate (MM/DD/YYYY)

e.g. John Smith 555-55-5555 01/01/1999

1 Employee:

2 Spouse:

3 Child:

4 Child:

5 Child:

6 Child:

7 Child:

8 Child:

REMEMBER YOUR DEPENDENT NUMBERS! THIS IS KEY TO THE ENROLLMENT PROCESS!

Benefit Plan Selections - Choose None or a Coverage Option and Dependent Status Code.

Employee Life Insurance and Accidental Death & Dismemberment*

Choose a Coverage Option

Option 1 Core Benefit- $10,000	no Weekly Cost
	Weekly Cost
	Age < 30	Age 30-39	Age 40-49	Age 50-59	Age 60-69
Option 2 $20,000	1.06	1.20	1.64	3.21	6.95
Option 3 $30,000	1.47	1.74	2.62	5.76	13.24
Option 4 $40,000	1.87	2.29	3.60	8.31	19.53
Option 5 $50,000	2.28	2.83	4.58	10.86	25.81

*You must choose a beneficiary by completing the Beneficiary Election Form found in your enrollment packet.

Large Amount Accidental Death & Dismemberment FOR ACCIDENTS ONLY

This benefit is available for dependent children age 14 days-19 years and spouses to age 70

Short Term Disability

Coverage starts on the 1st day for an accident or the 8th day for an illness for a maximum of 26 weeks

Vision Care

List the dependent number of each dependent to be covered.

	Plus (If applicable):
		Family Continuation Riders (One per Child age 19-25) cost= $1.50 per rider

Benefit Plan Selections- Choose Coverage Option and Dependent Status Code

Dental Plans

List the dependent number of each dependent to be covered.

Option 2 Details:
Plan 1 -- $25/$50 Deductible, 100%/80%/50%/50%, $1000 Annual Max, $1000 Ortho Max

Employee Only cost=0.00
Employee Plus One cost=0.00
Employee Plus Two or More cost=0.00

	Plus (if applicable):
		Family Continuation Riders (One per each Child age 19-25) cost=0.00 per rider

Option 3 Details:
Plan 2 -- No Deductible, 100%/80%/50%/50%, $1000 Annual Max, $1000 Ortho Max

Employee Only cost=1.60
Employee Plus One cost=3.09
Employee Plus Two or More cost=4.05

	Plus (if applicable):
		Family Continuation Riders (One per each Child age 19-25) cost=0.99 per rider

Health Plans

Option 1 Details:
(Opt out ONLY with proof of coverage elsewhere. Please forward a copy of your current health plan ID card to the Human Resources Department.)

List the dependent number of each dependent to be covered

Option 2 Details:
Employee Only cost=21.14
Employee Plus One cost=43.74
Employee Plus Two or More cost=51.62

	Plus (If applicable):
		Family Continuation Riders (One per each child age 19-25) cost=10.81 per rider

Option 3 Details:
Employee Only cost=10.32
Employee Plus One cost=21.62
Employee Plus Two or More cost=24.58

	Plus(if applicable):
		Family Continuation Riders (One per Each Child age 19-25) cost=5.41 per rider

Option 4 Details:
Employee Only cost=0.00
Employee Plus One cost=0.00
Employee Plus Two or More cost=0.00

	Plus (if applicable):
		Family Continuation Riders (One per Each child age 19-25) cost=0.00 per rider

Option 5 Details:
Employee Only cost=6.87
Employee Plus One cost=14.22
Employee Plus Two or More cost=17.18

	Plus (if applicable):
		Family Continuation Riders (One per Each Child age 19-25) cost=3.43 per rider

Note: To enroll in a health plan, you must complete the subscriber application found in your enrollment packet and return it to the Human Resources Department

Non-Smoker CREDIT

If you choose a health plan (above) and you have not used tobacco products since January 1, 1998, then verify this with your initials and take an extra credit of 75¢.

Total Weekly Pre-Tax Benefit Cost/Credit to You:
(Add Boxes B-H)

Total cost so far:

*If your benefit cost is a positive number, then that amount will be deducted from your weekly paycheck on a pre-tax basis
*If your benefit cost is a negative number, you may elect to take 60% of the excess in cash as taxable income or you may deposit 100% of the excess into the Medical Reimbursement Account, the Dependent Care Reimbursement Account or both.

Allocation of Benefit Credit

This section should be completed only if the total in Box I is a CREDIT.

MEDICAL REIMBURSEMENT ACCOUNT	DEPENDENT CARE REIMBURSEMENT ACCOUNT	CASH($.60 on a $1.00) of TAXABLE WAGES
Maximum weekly: $67.31(Including any pre-tax deferalls below)	Maximum Weekly: $96.15(Including any pre-tax deferalls below)	$ x.60=$ Gross Net 60%

Pre-Tax Flexible Spending Account Options

If you choose, you can elect to deposit ADDITIONAL money on a pre-tax basis into either the medical reimbursement account, the dependent care reimbursement account or both; however, the money may not be taken from one account and transferred to the other. The choice can only be made once each plan year and cannot be changed except in the event of qualified status changes such as marriage, divorce, death of a spouse, birth, death or adoption of a child, or spouse's change of employment. At the end of the plan year, any money not used must, by law, be forfeited.

I elect to reduce my weekly wages and put the money into the following accounts:

Medical Reimbursement Account

per weekly pay period. Minimum amount is $5.00; maximum amount is $28.85($1500 per year, including any pre-tax deferrals above)

Dependent Care Reimbursement Account

per weekly pay period. Minimum amount is $5.00; maximum amount is $96.15($5000 per year, including any pre-tax deferrals above)

After-Tax Benefit Selection- Choose none or a Coverage Option

Dependent Life Insurance

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