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Your Team. Our Community's Healthcare Heroes.

Welcome to our Open Enrollment Platform! We’ll definitely miss the personal interaction with each of you this year but completely understand the safety precautions that must remain in place. We have worked hard to create a simple, easy to use tool for you.

At Randy Reichardt Insurance Agency, we value the opportunity to facilitate the benefit options for you and your loved ones.

Friendly Reminder: Everyone who elects ANY benefits MUST complete the Cafeteria/FSA form.

Be well, and our best for a healthier 2022 for our community and our healthcare heroes.

Randy, Deanna, Alicia and Tiffany

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Benefit Confirmation Form

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
NOTE: IF YOU REQUIRE CONTACT FROM THE ENROLLMENT TEAM REGARDING ONE OR MORE OF YOUR BENEFITS BELOW, PLEASE PROVIDE CONTACT PREFERRED METHOD AND BEST TIME TO CONTACT:
Phone*
Email*
TASC
Please choose the option that best describes you*
- I wish to participate with an annual Medical FSA deduction
- I wish to participate with an annual Dependent Care FSA deduction
- I have been offered the opportunity to participate in my employer’s FSA/DCAP plan and would like to waive this benefit
Please Enter Amount for Annual Medical FSA*
Please Enter Amount for Annual Dependent Care*
Health
Please choose the option that best describes you*
- Coverage confirmed with no required changes for myself and/or dependents
- Changes are required, please contact me via mode identified above
Please choose the option that best describes you*
- I am NOT requesting spouse coverage on medical insurance
- I AM requesting medical coverage on my spouse and it is NOT offered through their employer
- I AM requesting medical coverage on my spouse and it IS offered through their employer
Dental
Please choose the option that best describes you*
- Coverage confirmed with no required changes for myself and/or dependents
- Changes are required, please contact me via mode identified above
Vision
Please choose the option that best describes you*
- Coverage confirmed with no required changes for myself and/or dependents
- Changes are required, please contact me via mode identified above
Cancer
Please choose the option that best describes you*
- Coverage confirmed with no required changes for myself and/or dependents
- Changes are required, please contact me via mode identified above
Accident
Please choose the option that best describes you
- Coverage confirmed with no required changes for myself and/or dependents
- Changes are required, please contact me via mode identified above
Life
Please choose the option that best describes you*
- Coverage confirmed with no required changes for myself and/or dependents
- Changes are required, please contact me via mode identified above
NOTE: Disability is an employer-provided benefit that doesn’t require confirmation.
Choose one of the following:*
- If you participate in your employer’s health insurance plan, your premiums will automatically be deducted on a pre-tax basis. I understand that this election will continue and cannot be revoked during the plan year unless there is a qualifying event.
- I have been offered the opportunity to participate in my employer’s employee benefit program and I decline. I understand that if I want to participate later, I may have to furnish evidence of insurability.
Sign by Typing Your Name*

Enrollment Application

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Cancer

Cancer Info Sheet

Cancer Screening Form

Enrollment Link

Screen Shot on 2020-09-29 at 15-18-22

Accident

Accident Info Sheet

Wellness Claim Form

Enrollment Link

Vision One Plan

Short Term Disability Plan

Whole Life Brochure

Benefit Highlights

Membership Info

Membership Application

Flex System Info

Highlight Sheet

Highlight Sheet

Financial Advisor Information

Call Email Claims Payments

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