Cardinal Insurance Form


Form for Employers interested in offering Cardinal Dental/Vision/Life plans to employees.

 

PROVIDER: CARDINAL SERVICES, CARDINAL EMPLOYERS ORGANIZATION, PREFERRED EMPLOYER SOLUTIONS

 

Click the links below for Plan Summaries and Rates

Dental Plan Summary & Document

Life Plan Summary

Vision Plan Summary & Document

 

The effective date would be 1st of the month after at least one month on Provider’s payroll PLUS one-month initial open enrollment period. See Provider for exceptions. Example: Date of hire: 1/15/2022 One-month on Provider’s payroll: 2/15/2022 One-month Initial open enrollment: 3/15/2022 Eligible Effective date: 4/1/2022

Complete the information for plans Employer would like to offer employees:

DENTAL PLAN

Premium Rates are subject to change annually.
Enter Coverage Amount $
Enter Coverage Amount $

VISION PLAN

Enter Amount and Unit of measure % or $
Enter Amount and Unit of measure % or $

LIFE PLAN

Enter Amount and Unit of measure % or $
Enter Amount and Unit of measure % or $
Please note:

Employer to provide at least 30 days notification to Provider for any plan offering &/or Employer contribution changes.

Employment Status: Employer to notify Provider of employees’ employment status (Full time, Part time or Temporary/Seasonal), and changes to employment status in a timely manner. Employer is solely responsible for unpaid premiums, mid-term policy cancellations fees/funding, if any, or unpaid premiums that are uncollectable. Provider will invoice Employer for any unpaid fees or premium.

Premiums: Unless notified otherwise by Employer, employee premiums are withheld on a pre-tax basis (except where not allowed per IRS ruling). If pre-tax premiums are involved, employees may not make changes to their elections (which includes dropping their dependents’ coverage) outside of the annual plan renewal unless they experience an eligible Qualifying Event.

Inform Cardinal of any employees related to owners. Complete Online Form.