GoTechNow HR and Insurance Forms

 

Fax forms to 214-615-2626 (no cover page needed)

 

The medical insurance below is effective September 1, 2009.  The dental, vision, life, and AD&D is effective August 1, 2009. 

 

 

 

Miscellaneous HR Forms

 

I-9 Form

 

W-4 Form

 

Direct Deposit Form

 

Bi-weekly Time Sheet

 

W2 Signup Checklist – MANDATORY – YOU MUST COMPLETE THIS TO GET PAID

 

MAJOR MEDICAL

The major medical is through Blue Cross Blue Shield (http://www.BCBSTX.com).  We have two plan options.  One is a qualified high deductible health plan which allows you to open a health savings account to grow your money tax free while saving you substantial money on insurance premiums, and the other plan is a traditional PPO that has much higher premiums but does not allow you to open a health savings account.  Both plans are with Blue Cross Blue Shield of Texas.

 

Please read the following notice regarding CHIP/HIPPA enrollments effective April 1, 2009:  CHIP HIPAA Special Enrollment Notice

 

When does the insurance take effect?  The insurance plans starts on the first calendar day of the month following 30 days of employment. For example if your start date was April 1st, after 30 days of employment (May 1), then the benefits start June 1st. 

 

You can find their doctor list here:

http://www.bcbstx.com/onlinedirectory/index.htm (select Blue Choice network).

 

Rates:

 

Employee Contribution

 

Employee Contribution

 

Per Month

 

Per Check

205

HSA

PPO

 

HSA

PPO

Employee Only

0.00

50.46

 

0.00

25.23

Employee + Child

106.52

321.62

 

53.26

160.81

Employee + Spouse

160.66

413.72

 

80.33

206.86

Employee + Family

319.98

684.86

 

159.99

342.43

 

 

Benefits summary (Health Savings Account plan):

Lifetime maximum:

$2,000,000

Coinsurance:

N/A

Deductible (EE/EF):

$5,000/$10,000 in network /$10,000 / $20,000 out of network

Doctor copay:

N/A

Max out of pocket (EE/EF):

$5,000/ $10,000 in network / $20,000 / $40,000 out of network

Rx coverage:

100% after calendar year deductible

Enrollment:

1st of the month following 30 days of employment

  You generally pay 100% of the discounted contract rate until you meet your deductible, then the insurance pays

Detailed HSA Summary of Benefits

 

Consolidated Enrollment Forms for Medical, Dental, Vision, STD, AD&D, Life (you must turn in either an enrollment form OR a waiver form for the medical insurance)

 

 

Benefits summary (PPO):

Lifetime maximum:

$5,000,000

Coinsurance:

80% in network/ 60% out of network

Deductible:

$2,000 in network

Doctor copay:

$30 (Urgent Care - $55)

Max out of pocket (EE/ EF):

$3,000 / $9,000 in network / $6,000 per person out of network

Rx – Generic copay:

$20

Rx – Brand copay:

$40

Rx – Non-preferred:

$60

Enrollment

1st of the month following 30 days of employment

Detailed PPO Summary of Benefits Link

 

Consolidated Enrollment Forms for Medical, Dental, Vision, STD, AD&D, Life (you must turn in either an enrollment form OR a waiver form for the medical insurance)

 

Health Savings Account

When you enroll in a qualified high deductible health plan, you are covered for serious illness or injury by a high deductible (lower premium costs) insurance plan.  You can then set up a health savings account (HSA) on your own.  You can make tax-deductible contributions to an HSA to pay for qualifying medical expenses. The maximum amount per year you can put in this account is limited to the lower of the plan’s annual deductible amount or the statutory maximum as adjusted annually (up to $5,650 for a family in 2007).  The best thing about a health savings account is that it can function like an IRA:  you can put money in and let it grow tax deferred until you use it.  You don’t have to use the HAS to pay for uncovered medical expenses, but if you do then you can withdraw the money tax free.  GoTechNow recommends setting up an HSA with Sutton Bank (http://www.suttonbank.com/Sutton+Bank/Personal+Accounts/HSAaccount/HSAaccount.htm ) because it allows you to transfer your money into a brokerage account with OptionsXpress to invest in a broader range of securities (most banks just pay low interest rates on HSA accounts).

 

For questions about the insurance not covered here call Blue Cross Blue Shield @ 1-800-521-2227 (group #7563).

 

 

DENTAL

The dental insurance is through Dental Select (http://www.DentalSelect.com).

 

When does the insurance take effect?  The insurance plans starts on the first calendar day of the month following 30 days of employment. For example if your start date was Apirl 1st, after 30 days of employment (May 1), then the benefits start June 1st. 

 

Rates:

 

DMO Plan

PPO Plan

 

Deduction Per Month

Deduction Per Pay Period

Deduction Per Month

Deduction Per Pay Period

Employee only:

$10.94

$5.47

$23.26

$11.63

Employee + spouse:

$23.14

$11.57

$61.92

$30.96

Employee + Children

$25.02

$12.51

$63.68

$31.84

Employee + Family: 

$32.82

$16.41

$91.72

$45.86

 

Benefits:

 

DMO

PPO

Annual deductible

None

$50

Annual benefit

Unlimited

$1,000

Max orthodontics benefit

Included

N/A

Preventive

Scheduled

100%

Basic

Scheduled

80%

Major

Scheduled

50%

Orthodontics

Scheduled

N/A

 

Scheduled copayments by procedure (DMO only)

 

Detailed summary of benefits link (PPO only)

 

Consolidated Enrollment Forms for Medical, Dental, Vision, STD, AD&D, Life (you must turn in either an enrollment form OR a waiver form for the medical insurance)

 

For questions about the insurance not covered here call Dental Select @ 800-999-9789 (group # 11000092).

 

 

VISION

The vision insurance is through AIG.   When does the insurance take effect?  The insurance plans starts on the first day of the month following one month of employment. For example if your start date was April 1st, then the benefits start May 2nd.

 

                                                                Deduction    Deduction

                                                                Per Month    Per Pay

Rates:                                                                             Period           

Employee only:

$7.56

$3.78

Employee + spouse:

$14.34

$7.17

Employee + Children

$15.10

$7.55

Employee + Family: 

$21.90

$10.95

 

Benefits:

Exam

$10 exam once per year

Lenses

24 months

Frames

24 months

Contacts

$105 allowance

Rate guarantee

2 years

 

Detailed summary of benefits link

 

Consolidated Enrollment Forms for Medical, Dental, Vision, STD, AD&D, Life (you must turn in either an enrollment form OR a waiver form for the medical insurance)

 

 

SHORT TERM DISABILITY

The short term disability insurance is through AIG.

 

Short Term Disability (Optional Insurance)

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE SUMMARY

 

 

 

 

 

Payroll deductions per year:

24

 

 

 

 

Benefit percent:

 

 

60%

 

 

 

 

Maximum weekly benefit:

$500

 

 

 

 

Minimum weekly benefit:

$25

 

 

 

 

Day benefits start (accident/sick):

8th day

 

 

 

 

Benefit duration:

 

13 weeks

 

 

 

 

Pre-existing exclusion:

 

12 month lookback / 12 month exclusion

Contribution:

 

 

100% employee paid

 

 

Occupation:

 

 

Doesn't cover work illness/ injury

 

Maternity:

 

 

Included

 

 

 

 

To calculate your premium:

 

 

 

 

 

Based on weekly salary to a maximum benefit of $500

 

 

 

 

 

 

(excluding overtime and bonus)

 

 

Weekly salary =

 

X

Benefit %

60%

= Weekly Benefit

 

 

 

 

 

 

 

 

 

 

Example:

 

 

 

 

 

 

 

Weekly salary =

833.33

X

Benefit %

60%

= Weekly Benefit

$500

 

 

 

 

 

 

 

 

 

Look up the weekly benefit and your age below to calculate the premium

 

 

 

 

 

 

 

 

 

Premium cost per check (24 checks per year):

 

 

 

Weekly

Ages

Ages

Ages

Ages

Ages

Ages

Ages

Ages

Benefit

up to 30

30-39

40-44

45-49

50-54

55-59

60-64

65 +

$50

$0.90

$0.95

$1.13

$1.33

$1.58

$1.95

$2.38

$2.88

$60

$1.08

$1.14

$1.35

$1.59

$1.89

$2.34

$2.85

$3.45

$70

$1.26

$1.33

$1.58

$1.86

$2.21

$2.73

$3.33

$4.03

$80

$1.44

$1.52

$1.80

$2.12

$2.52

$3.12

$3.80

$4.60

$90

$1.62

$1.71

$2.03

$2.39

$2.84

$3.51

$4.28

$5.18

$100

$1.80

$1.90

$2.25

$2.65

$3.15

$3.90

$4.75

$5.75

$110

$1.98

$2.09

$2.48

$2.92

$3.47

$4.29

$5.23

$6.33

$120

$2.16

$2.28

$2.70

$3.18

$3.78

$4.68

$5.70

$6.90

$130

$2.34

$2.47

$2.93

$3.45

$4.10

$5.07

$6.18

$7.48

$140

$2.52

$2.66

$3.15

$3.71

$4.41

$5.46

$6.65

$8.05

$150

$2.70

$2.85

$3.38

$3.98

$4.73

$5.85

$7.13

$8.63

$170

$3.06

$3.23

$3.83

$4.51

$5.36

$6.63

$8.08

$9.78

$190

$3.42

$3.61

$4.28

$5.04

$5.99

$7.41

$9.03

$10.93

$210

$3.78

$3.99

$4.73

$5.57

$6.62

$8.19

$9.98

$12.08

$220

$3.96

$4.18

$4.95

$5.83

$6.93

$8.58

$10.45

$12.65

$240

$4.32

$4.56

$5.40

$6.36

$7.56

$9.36

$11.40

$13.80

$260

$4.68

$4.94

$5.85

$6.89

$8.19

$10.14

$12.35

$14.95

$280

$5.04

$5.32

$6.30

$7.42

$8.82

$10.92

$13.30

$16.10

$300

$5.40

$5.70

$6.75

$7.95

$9.45

$11.70

$14.25

$17.25

$350

$6.30

$6.65

$7.88

$9.28

$11.03

$13.65

$16.63

$20.13

$400

$7.20

$7.60

$9.00

$10.60

$12.60

$15.60

$19.00

$23.00

$500

$9.00

$9.50

$11.25

$13.25

$15.75

$19.50

$23.75

$28.75

 

Detailed summary of benefits

 

Consolidated Enrollment Forms for Medical, Dental, Vision, STD, AD&D, Life (you must turn in either an enrollment form OR a waiver form for the medical insurance)

 

 

LONG TERM DISABILITY

 

The long term disability insurance is through AIG.

 

Long Term Disability (Optional Insurance)

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURANCE SUMMARY

 

 

 

 

 

 

Payroll deductions per Year:

24

 

 

 

 

 

Benefit percentage:

 

60%

 

 

 

 

 

Maximum monthly benefit:

$6,000

 

 

 

 

 

Elimination period:

 

90 days

 

 

 

 

 

Benefit duration:

 

To age 65

 

 

 

 

Integration:

 

Full family

 

 

 

 

Pre-existing exclusion:

12 month lookback / 12 month exclusion

 

Contribution:

 

100% employee paid

 

 

 

Occupational coverage:

Covers work and non-work related illness/ injury

Own occupation period:

2 years

 

 

 

 

 

Partial definition:

 

Progressive partial (covers partial loss of pay)

Mental illness limit:

 

24 months

 

 

 

 

Drug and alcohol limit:

24 months

 

 

 

 

Survivor benefit:

 

3 months monthly benefit

 

 

 

Minimum benefit:

 

$100.00 or 10% gross monthly benefit

 

 

 

 

 

 

 

 

 

 

To calculate your premium:

Based on monthly salary to a maximum benefit of $6,000

 

 

 

(excluding overtime and bonus)

 

 

Monthly salary =

 

X

Benefit %

60%

= Monthly benefit

 

 

 

 

 

 

 

 

 

 

Example:

 

 

 

 

 

 

 

 

Monthly salary =

5,000

X

Benefit %

60%

= Monthly benefit

$3,000

 

 

 

 

 

 

 

 

 

Look up the monthly benefit and your age below to calculate the premium

 

 

 

 

 

 

 

 

 

 

Premium cost per check (24 checks per year):

 

 

 

 

Monthly

Ages

Ages

Ages

Ages

Ages

Ages

 

 

Benefit

up to 30

30-39

40-44

45-49

50-54

55  +

 

 

$500

$1.33

$2.25

$3.65

$5.35

$7.55

$9.10

 

 

$600

$1.59

$2.70

$4.38

$6.42

$9.06

$10.92

 

 

$700

$1.86

$3.15

$5.11

$7.49

$10.57

$12.74

 

 

$800

$2.12

$3.60

$5.84

$8.56

$12.08

$14.56

 

 

$900

$2.39

$4.05

$6.57

$9.63

$13.59

$16.38

 

 

$1,000

$2.65

$4.50

$7.30

$10.70

$15.10

$18.20

 

 

$1,100

$2.92

$4.95

$8.03

$11.77

$16.61

$20.02

 

 

$1,200

$3.18

$5.40

$8.76

$12.84

$18.12

$21.84

 

 

$1,300

$3.45

$5.85

$9.49

$13.91

$19.63

$23.66

 

 

$1,400

$3.71

$6.30

$10.22

$14.98

$21.14

$25.48

 

 

$1,500

$3.98

$6.75

$10.95

$16.05

$22.65

$27.30

 

 

$1,600

$4.24

$7.20

$11.68

$17.12

$24.16

$29.12

 

 

$1,700

$4.51

$7.65

$12.41

$18.19

$25.67

$30.94

 

 

$1,800

$4.77

$8.10

$13.14

$19.26

$27.18

$32.76

 

 

$1,900

$5.04

$8.55

$13.87

$20.33

$28.69

$34.58

 

 

$2,000

$5.30

$9.00

$14.60

$21.40

$30.20

$36.40

 

 

$2,200

$5.83

$9.90

$16.06

$23.54

$33.22

$40.04

 

 

$2,400

$6.36

$10.80

$17.52

$25.68

$36.24

$43.68

 

 

$2,600

$6.89

$11.70

$18.98

$27.82

$39.26

$47.32

 

 

$2,800

$7.42

$12.60

$20.44

$29.96

$42.28

$50.96

 

 

$3,000

$7.95

$13.50

$21.90

$32.10

$45.30

$54.60

 

 

$3,500

$9.28

$15.75

$25.55

$37.45

$52.85

$63.70

 

 

$4,000

$10.60

$18.00

$29.20

$42.80

$60.40

$72.80

 

 

$4,500

$11.93

$20.25

$32.85

$48.15

$67.95

$81.90

 

 

$5,000

$13.25

$22.50

$36.50

$53.50

$75.50

$91.00

 

 

$6,000

$15.90

$27.00

$43.80

$64.20

$90.60

$109.20

 

 

 

Detailed summary of benefits

 

Consolidated Enrollment Forms for Medical, Dental, Vision, STD, AD&D, Life (you must turn in either an enrollment form OR a waiver form for the medical insurance)

 

 

LIFE / ACCIDENTAL DEATH & DISMEMBERMENT

 

The life and ADD insurance is through AIG.  The first $15,000 of insurance is paid by GoTechNow, but you have to complete the enrollment form to get it.  Additional life insurance is not available due to lack of interest during initial enrollment.

 

Detailed summary of benefits

 

Designation of beneficiary link

 

Consolidated Enrollment Forms for Medical, Dental, Vision, STD, AD&D, Life (you must turn in either an enrollment form OR a waiver form for the medical insurance)

 

 

401(k) PLAN

 

We offer a 401(k) plan through Fidelity Investments for those people who have been with us for one year or more. . 

 

Online enrollment educational video:  http://www.brainshark.com/fidelityemg/Enrolling_in_Your_401k

 

Other documents:

 

Fidelity brochure

 

Fidelity enrollment guide

 

Fidelity Enrollment Election Form

 

Fidelity Participant Change Form

 

Fidelity Safe Harbor Matching Notice