TEAM STAFFING SERVICES EMPLOYMENT APPLICATION

LAST NAME:

FIRST NAME:

ADDRESS:

CITY:

ZIP:

STATE: ALTERNATE#:

HOME#:

SOCIAL SECURITY#:

DRIVER LICENSE#:

Expiration:

STATE: HOURLY RATE EXPECTED:

PERM:

TEMP:

DAYS AVAILABLE TO WORK: S M EMPLOYMENT HISTORY:

T W

HOURS AVAIL:

TH F S

TO:

LAST MINUTE:

YES

NO

COMPANY ADDRESS:

TO:

FROM:

EMAIL ADDRESS:

SUPERVISOR AND PHONE#: COMPANY ADDRESS:

TO:

FROM:

SUPERVISOR AND PHONE#: TO:

FROM:

COMPANY ADDRESS:

SUPERVISOR AND PHONE#: PLEASE CIRCLE SKILLS: MACHINIST ASSEMBLERS HOSPITALITY

HOUSKEEPING

WAREHOUSE

FOOD/CHEF

UPHOLSTERY

DRAFTING

DRIVER

FORKLIFT

PRINTING

SECRETARIAL

OTHER:

PLEASE CIRCLE: TRANSPORTATION:

OWN CAR. .

BUS

DRIVER LICENSE:

YES

NO

STEEL TOE SHOES:

YES

NO

FORKLIFT CERTIFIED:

YES

NO

CLASS:

OTHER:

A

B

E

CAPABLE OF LIFTING:

DRIVER LICENSE VALID: 301BS

SOIBS

HAVE YOU BEEN CONVICTED OF A FELONY IN THE LAST (7) YEARS?

APPLICANTS SIGNATURE:

YES YES

NO

801BS

ARE YOU ELIGIBLE FOR EMPLOYMENT IN THIS COUNTRY?

IS THERE ANY REASON YOU MIGHT BE UNABLE TO PERFORM DUTIES?

YES

YES

NO

NO

NO

DATE:

I HERBYCERTIFY THAT THE INFORMATION ON THIS APPLICATION FORM ANO ANY ATTACHMENTS LISTED BELOW (HEREAFTER MADE A PART OF THIS APPLICATION) IS TRUE ANO CORRECT TO THE BEST OF MY KNOWLEDGE ANO AGREE TO HAVE ANY STATEMENTS CHECKED BY TEAM STAFFING SERVICES UNLESS I HAVE INDICATED TO THE CONTRARY.I AUTHORIZE THE REFERENCES umo ABOVE TO PROVIDE TSS ANY ANO ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THAT THEY MAY HAVE FURTHER, I RELEASE ALL PARTIES ANO PERSONS FROM ANY ANO ALL LIABLITY FOR ANY CHANGES.THAT MAY RESULT FROM FURNISHING SUCJH INFORMATION TO TSS AS WELL AS FROM USE OR DISCLOSURE OF SUCH INFORMATION BY TSS OR ANY OF ITS AGENTS, EMPLOYEES, ANO REPRESENTATIVES. I UNDERSTAND ANY MISREPRESENTATION, FALSIFICATION, OR MATERIAL OM MISSION OF IN FORMATION MAY RESULT IN MY FAILURE TO RECE IVE A JOB, OR IF IM HIRED, IN MY DISMISSAL FROM

Form W-4 (2014)

• It bind. or • Wll ci.n~= inclollle: •~ Ot llalllzillcl~C111llllorhlttmcrt1Lm.

A

B

c D E

F G

H

Enter "1" for yo&nllf if no one else can clllm you • a dependent • • • • • • • • • • • • • • You ant single and have oltf one job; or } Enter "1 • if: { • You are manied, haY8 Ol'l'f one job, Ind ~spouse does not wcr1c; or • YOIX wages from a seccnd job or yoc.r tpOUSt's wages (or the total of bcCt1) n $1,500 or leas. for 1JOA1 .,..._ But, you may choo8e to enter •-o-• If you are married and have eilher' a wortdng apouse or more than one job. (Ent8ring •.:o-• may help you aYCid having too liUle 1aX wlthheld.) • • • • • • • • • • • • enter iurarof dip indents (other than your tpCKme or~ )'OU wl claim on your tmx nmn • . • • • • • Enler "1" if )'OU wll tie as heed ol hou8ehald on your tmx 19tunt (988 ec1dtions undlr Head ol houe 1hold aboYe) Enter "1" if you hive at IWt $2.000 of chld or dependent m axpe1. . b' which you pllr1 to claim a credit • (NolL Do not Include chld afJPOrt payments. See Pub. 503. Child s1d Dependent Care Expa-. b' details.)

A

8

Enter.,.

c D E

F

Chld T.x Cndt (lncludin9 adcltloc181 child 1ax cndlQ. See Pub. 972, Child TIX Credit, for mare lldomllllior1o • If )'OU"totll income wl bt $86,000 ($96,000 if nwried), enter "2" b' a:l'I ellglble child; 1hen .... "1" lf )'OU hM tine to six eligible chtia1or1111 "2"' If you have . . i or men eligible chlldrln. • If yoxti:al inccm1 w1 be betwlerl $85,()00 Sid $84,000 ($195.000 and $119.000 if ITl8ITie4 erlllr "1" for llClh llgiblt ct*1 . • G Add Ines Attl'o&9J G ll1d erlllrtolB here. (Noll. Thll may be clffern from the runber cA ua1iptbis you cllllm on '{OAl1Bx rattm.) ~ H

'*'

• If~ plan to illlrnllt or alliln . . . , . . , . to Income and want to rlduGe )'OU" with.'lolcili;. . . the o.dllCllans a ............. WorlcehNtcn P1gt2. . For acc&ne)'. { co..,... .. •If~ ....... ,__men 9*' one job or se rnmlMI md-n:"=~ boCll wart and the comblll8d ~ from Iii )ca IOCIOeed 860,000 ($20.000 If married). aee the .fObs Wuotcll.- on page 210 worbhaea avoid ~ 11oo ltlle mx wlthheld. that apply. of the above litlJllionl epp!l!l. lllOP here and erlliel"the runblr from IN H an lne S of Fonn W-4 below.

md

• If.._,.

Employee's Wlthholdlng Allowance Certificate

OMS No. 154H074

~@14

s ave Mmri9d ....... tiut wtltlhald • ~ Sir9e-. . . . If msrild, bit ............. " . . . . . . . . . dllct.. "alglil" bait. 4 ,,,_. . . . . . . . . . . . . . . . . . . . . . . ,_...,....__....

D

cblGkllll'e. Yoa111111t0111~1211taru1plr:11n•cant. .- O

s Total runb« of llloWlllCel you are~ (from h Habove or from the appbbe wcx1cltieet on pmge 2) 6

7

....s.....,.____

Addltionll amouit. If any, )'OU want withheld from each paycheck • • • • • • • • • • • • • • 6 $ I claim exan1J1iOn from wilhholding for 2014, and I certify 1twt I meet both of the following COldtions for eiceniptioca. • Last Y8" I had a right to a t8fund of al federal Income tax withheld becaule I had no tax ilbillty, and • Tiiis yas-1 toq)eot a refund ot .. WJeim income tax withheld becauae I expect to have no tax :"'i~r------.-~

If you mMt both ccncltions, wrfte "Ex8mpr r.. .

. . . . . . . . . . . . . .

~

7

Undor per.mes of oerjLly, I dlCllra that I haW exanlllld this certiflclle and, to the best of my knowtedge MCI belllf, It is true,

~---­

(This form is not Ylld in.es )'OU !if? It.) •

ccrrwc:t. aid complete.

USCIS

Employment Eligibility Verification

Form 1-9

Department of Homeland Security

OMB No. 1615-0047

U.S. Citizenship and Immigration Services

Expires 03/31/2016

~ST ART HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Emplqyee Information and Attestation (Employees must complete and sign Section 1 of Form 1-9 no later than the first day of employment, but not before accepting a job offer.) Middle Initial Other Names Used (if any)

First Name (Given Name)

Last Name (Family Name) Address (Street Number and Name)

I

State

City or Town

Apt. Number

Telephone Number

Date of Birth (mmlddlyyyy) U.S. Social Security Number E-mail Address

DD-I

Zip Code

I

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following):

0

A citizen of the United States

O A noncitizen national of the United States (See instructions) 0 A lawful permanent resident (Alien Registration Number/USCIS Number): - - - - - - - - - - -

0

An alien authorized to work until (expiration date, if applicable, mm/ddlyyyy) - - - - - - - · Some aliens may write "N/A" in this field . (See instructions) For aliens authorized to work, provide your Alien Registration Number/USC/$ Number OR Form 1-94 Admission Number: 1. Alien Registration Number/USCIS Number: _ _ _ _ _ _ _ _ _ __

3-D Barcode Do Not Write in This 'Space

OR 2. Form 1-94 Admission Number:- - - - - - - - - - - - - - If you obtained your admission number from CSP in connection with your arrival in the United States, include the following: Foreign Passport Number: - - - - - - - - - - - - - - - - - - - - - Country of Issuance: - - - - - - - - - - - - - - - - - - - - - - - -

Some aliens may write "NIA" on the Foreign Passport Number and Country of Issuance fields. (See instructions)

I

IDate (mmlddlyyyy):

Signature of Employee:

Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by~ perion other than the employee.)

·

I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct

J

Signature of Preparer or Translator: Last Name (Family Name) Address

(Street

Number and Name)

Date (mmlddlyyyy):

First Name (Given Name) r ity or Town

! State

l Zip Code

Employer Completes Next Page Form 1-9 03108113 N

Page 7 of9

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized rep~ntative must complete and sign Section 2 within 3 business days ·ofthe employee's first day of employment. You must physica(ly examine one document from Ust A OR examine a combination of one document fro"! Ust B ·and one .document from Ust C as listed on the ·usts of Acceptable Documents•on the next page of this form. For each document you review, record the·folloWing information: doclfment title, issuing authority, document number, ·and expiration date, ff any.) Employee Last Name, First Name and Middle Initial from Section 1:

List A

OR

Identity and Employment Authorization Document Title:

Issuing Authority:

AND

ListC Employment Authorization Document Title:

List B Identity

Document Title:

Issuing Authority:

:. Issuing Authority: ,,

Document Number:

Document Number:

Document Number:

.!

Expiration Date (ff any)(mmlddlyyyy):

'; Expiration Date (ff any)(mmldd/yyyy):

Expiration Date (if any)(mmlddlyyyy):

....

Document Title: Issuing Authority: Document Number:

'

~ "

If F.l

Expiration Date (if any)(mmlddlyyyy): Document Title: Issuing Authority:

3-D Barcode Do Not Write in This Space

~j

~ ·:r ~.~

Document Number: Expiration Date (if any)(mmlddlyyyy):

Certification I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.

l

The employee's first day of employment (mmlddlyyyy): Signature of Employer or Authorized Representative

Last Name (Family Name)

1

(See instructions for exemptions.)

Date (mm/ddlyyyy)

l

First Name (Given Name)

Title of Employer or Authorized Representative

Employer's Business or Organization Name

Tf.Af'I\ .

Employer's Business or Organization Address (Street Number and Name)] City or Town

(,,:1::20_2. O~T ~5"lt

ST~~\WC:t . S'~V\.~S State

0~~

l=-C

Zip Code

3:i.~0Et

.

Section 3. Rev~rifiqtiijn . andJ~ebires (To be completed and signed byemployerorai4fhoriz°eo~--~ ..

~---1D~fmd Hid •*'to fllllrtllOltilr' oreb:w '- -·-

iorclwsbl~

~

y

!RAVE YOU EVER HAO:

~ R:lldorl tDdnCI

....

.

'-·

or c:aawlliow• _.,_

...

~otrMeim11i1n .....

islila,.,_or....,.

~

...

•I"""

~~ i;;

.,.:::;:

. !Wit. . .

.......

~

It

...

. ~VE YOU EVER HAD:

...

bss dcae or bell-

·~

ytJJfJI aec:k

r:......-...dlzl'ltpells .

I-

H

~ or iiulld YDar«**

llllmlY.,

~- . . . . lllfhg

lruben:ulosis ~RMI'

!Polio

tmd8etes 16Rcat~

""'1 blood~

•

~ atacllftdCf l:IOlleS Aid an-lnbYtio.~.a.t or Nnd bo~.- ....... ald

L...

~d !Nerve troub'e

N

. . _ _ _ CD _.,1c19e

lseen aClwiled to . . . ~reiedldfor!be----

If.tad a bemia or nipCUl8

«baa

~-~tDY'OUl'ble

~ at'tj serious meclcll llnees

IBeeri tafuled •

·--

y

pi;ll' -~-

jH.dZ'IV

......

JfAVE YOU EVER:

far a bai*lllGOCWt jDo yo&r UM l!lff mecl «kin regufarty, ower the c:iounllif'

•• ;f11my811111)

wodGef's

ZIP_ _ _ __

~ ~

IPillli/

...lu..air..&.. Scilrolil

._........

IBloocf c:1cD r

v-....

PIB;Il

' .....

.

_..

y

N

Employee Direct Deposit No More Extra Trips To The Bank! To request Direct Deposit of your paydleck, rad and eomplctc tbc following au!horization agreement, and gj\oe it to your payroll depanment. lfyou &R eligible 10 partieipll!C, lhcy'll set )'OU up·on Direct Deposit.

Please de

it m entire net a into the accounts

·fied below.

Cbeckillg Bank Name: ____________________

Account#:~-------------------~ Routing/Transit#: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

~

If you are splitting your deposit, please select the second account and mark the percentage or the correct dollar amount to be deposited CirclcOne:

Checking

Savings

Bank Name:~--------------------

Account#:--------------------~ Routing/Traasit#: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ At!ld! a void check. b!gk letter. or specjfiqtiop sbeet Deposit ticlc.e!s are NQT accepted.

S litamoaat

"' Or flat dollar amount

s

EMPLQYEE INFORMATION Nam~~---------------------~ SociaJSecarity#: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ (UQVJUD)

Home Address:~------------------~ SDte: _ _ _ _ _ _ _ _ _ _ _ _ _ Zip:...,...._ _ _ _ _ __ Responsibility of Employees Upon emolling in !be direct depocit progrmi, the Employee will affirm whclher lbc enitrc payment llllOllllt, is or is noc, subjoc:l 10 being forwarded to a bank in lllOCbei' COUllCI)'. Sbould die Employee's IAT S181Us chanse at any time in lbc fulure, the Employee should notify the SIMO or die inquiriiia agency. Sbould Ille Employee RQl'ive payroll via dircc:t deposit 11% a U.S. fimmQal inslihmon and tbcol haYC die en!ire payroll amount forwmdod IO a bank in anodiec COUllCly, lbc Employee should advise diem cllmt ame may provide a ,_..al DOtioe ieprcliaa die IAT ndcs. or it may make a specific inquiry of you. If!be Emplo)"ee docs not adllise dimt tbat the Employee meets the dcfiililicD of m IAT payee, tbc ~will be presumed to be a IXIO-IAT payw. Sbould !be &aployec's !AT status~ ax my time in tbc famre, tbc .Employee sbOaJd ~ etieat aame.

Please indicate if tbe Employee is an IA T payee by placing a check bcre: ( )

AUTHORIZATION

->to

I aulbcrize my employer; dieat ~ dimt deposit my net pay acb payday directly iato my accouat ID Ille CYe11t !bat dieat aame deposils funds CITOllCOllSly illlo my - = i i , I bcrcby aadlorizo dieat IO debit my IC:llOlllll for llll llllOllllt DOt to exQeOd the oripal lllllOUlll of errooeom aedit. Arty dispute llisiD& oat at or iD c:omcUca wilh lhis apemcm. if not ocberwise l'elOlvcd, sball be detcrmiDed by arbilrllioa iD CleYebmd, Obio, in accordm:e wilh the Raia ot the AmcriQm ArllilraDon 4ssoc:iatioa, and it's the cxprcs.sod desire ofbodl pmties !bat lbe JnY1iJiDa peny be awarded Ille costs aDd llltemey's fees and dllt !be award be enlaecl as ajudamcnt in -jurisdielion in whicb

tbe---.

~does i-me..

This aulbcri1.atioa will t=ain in full fon:c and ~ uaril dieat ume and tbc Bmilc ha\le receiYed wrinen DOticc &om me ot its tcrminalion in sadi time and in sadi mamicr as to aft'ord dieat name and Bmilc a reasonable opportunity 10 act on it. >mpao,ccSipa1are: _ _ _ _ _ _ _ _ __ _ _o.1e: ______

VSI-IND

251 600-TST

OFFIC E USE O NLY

EMPLOY~E INFORMATION

(Must Be Fiiied Out)

ReHire Date _ _ ; _ _ ; _ _ _ _ PR l'.'\Tl .SING B~ .ACK orBI.l'E l'.'\ K !:SC !\A Pl' 13 .0

ENROLLMENT FORM_ PLAN J r

Social Security Number

D Yes D No

Sex ~[£]

Date of Birth

Do you or any dependents have Medicare? If Yes: Medicare Health Insurance Claim Number (HICN)

Name Medicare Effective Date Street Address

Names of Covered Person(s)

1. 2. 3.

Home Phone

BENEFIT SELECTION

Wed.: I)

MEDICAL

D $ 19.98 Employee Only D $40 .54 Employee+ One D $54.14 Employee+ Family

• ,

.,

You MUST enroll in the Medical Insurance Plan before adding any additional benefits. Your coverage level for the additional benefits will be identical to your medical plan selection.

REQUIRED DEPENDENT INFOR;\llATION Name _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Social Security Number

D IfNONOtoisallchecked, benefits. sign and date the bottom of the form .

I Date of Birth Relationship: D Spouse

Sex

D Child

~[£]

D Domestic Partner

This coverage is not approved by the NH Dept. of Insurance for purchase by an_y_resident of the state of New Ham25hire.

DENTAL D

YES

O

NO

$ 5.23 Employee Only $10.46 Employee+ One $I 7 .26 Em pl oyee + Fami l y

"

Name - - - - - - - - - - - - - - - - - - Social Security Number Date of Birth Relationship: D Spouse

Sex

D Child

~[£]

D Domestic Partner

VISION

O vES O

NO

$2.35 Employee O nly $4 .00 Employee + One $5.64 Employee+ Family

TERMLIFE $0.60 Employee Only $0 .90 Employee+ One $1 .80 Employee + Family

SHORT-TERM DISABILITY D

YES

O

NO

$4.20 Employee Only

Short-Term Disability is not available to persons who work in California , Hawaii , New Jersey, New York , or Rhode Island.

Name - - - - - - - - - - - - - - - - - - Social Security Number Date of Birth Relationship: D Spouse

Sex

~[£]

D Child D Domestic Partner

BENEFICIARY INFORMATION For Term Life I Accidental Death & Dismemberment, please write in your beneficiary information . NAME OF BENEFICIARY

RELATIONSHIP

Accidental Death & Dismemberment is part of the Term Life Benefit.

I have read the benefit packet and understand its limitations. I understand that open enrollment is only available for a limited time and I understand that making no benefit seleccion is a declination of coverage . ...... Signature Date _ _ 1 _ _ 1 _ _ _ _

STEP 1:

You MUST complete the Employee Information Section as part of your new hire process.

Essential StaffCARE Plan Information Packet Please keep for your records.

STEP 2:

You MUST Accept or Decline coverage.

PLEASE NOTE: Your Company has chosen to take your deductions on a Post-Tax basis.

Member Services: Essential StaffCARE Customer Service: 1-866-798-0803 •

Once enrolled, members can call this number for questions regarding plan coverage, ID card, claim status, policy booklets, and to add, change, or cancel coverage.

•

Customer Service Call Center hours are M - F, 8:30 a.m. to 8 p.m. Eastern Standard Time. Bilingual representatives are available.

•

Members can also visit www.essentialcare.com/members and click on Essential StaffCARE.

STEP3:

You MUST Sign and Date here. Even if you decline coverage.

._

FREQUENTLY ASKED QUESTIONS How do I enroll? Enrolling in the Essential StaffCARE plan is easy. You can enroll by completing an Essential StaffCARE enrollment application and returning it to your manager. When can I enroll in the plan? As a full-time and/or part-time employee, you are able to enroll in the Essential StaffCARE program within 30 days of your hire date, 1st paycheck date, or your employer's annual 30 day open enrollment period. If you do not enroll during one of these time periods, you will have to wait until the next annual open enrollment, unless you have a qualifying life event. You have 30 days from the date of the qualifying life event to enroll.

If I complete an enrollment form, but do not get placed on assignment right away, will I have to complete a new form?

After six months if there has not been a deduction from your paycheck, please fill out a new enrollment form. Missing information will delay the process. Can I make changes or cancel coverage?

What is a qualifying life event?

You may cancel or reduce coverage at any time unless your premiums are deducted pre-tax. You will only have 30 days from your hire date or first paycheck date to enroll, add additional benefits or add additional insured members. After this time frame, you will only be allowed to enroll, add benefits or add additional insured members during your annual open enrollment period or within 30 days of a qualifying life event.

A qualifying life event is defined as a change in your status due to one of the following:

(Please refer to the "PLEASE NOTE" section on the previous page to see if deductions are Post-Tax or Pre-Tax)

• • • • • • • •

Marriage or divorce Birth or adoption of a child(ren) Termination Death of an immediate family member Medicare entitlement Employer bankruptcy Loss of dependent status Loss of prior coverage

In addition, you may request a special enrollment (for yourself, your spouse, and/or eligible dependents) within 60 days (1) of termination of coverage under Medicaid or a State Children's Health Insurance Program (SCHIP), or (2) upon becoming eligible for SCHIP premium assistance under this medical benefit.

How can I make changes? To make changes or cancel coverage by telephone call (800) 269-7783. Enter your PIN CODE plus the last four digits of your Social Security number (SSN). PIN CODE: 142 + (last four digits of your SSN) Remember, it may take up to two or three weeks for the changes or cancellation to be reflected on your paycheck. Coverage will continue as long as you have a paycheck deduction. Is there a pre-existing clause for the Medical Benefit?

Yes. Eligible dependents include your spouse and your children up to age 26.

There are no restrictions for pre-existing conditions in this medical plan. Even if you were previously diagnosed with a condition, you can receive coverage for related services as soon as your coverage goes into effect.

When does coverage begin?

Is there coverage for contraceptives on this plan?

Coverage will begin the Monday following a payroll deduction and continues as long as you have a deduction from your paycheck. Please review your check stub for deductions. If you miss a payroll deduction, to avoid a break in coverage, you may make direct payments to PAI. After six consecutive weeks without a payroll deduction or direct premium payment, coverage will be terminated and COBRA information will be sent at that time.

Oral contraceptives are covered under the prescription benefit. Non-oral contraceptives are not covered.

Are dependents covered?

Are maternity benefits covered? Yes, maternity benefits are covered the same as any other condition under this plan.

NETWORK INFORMATION Prescription Drug Network

Medical

If enrolled in the medical plan, you are automatically covered by the prescription drug program through the Caremark Pharmacy Network. Caremark has a national network with over 58 ,000 participating pharmacies. To find a local participating Caremark pharmacy, you can visit www.caremark.com. Prescription drug benefit information can be found on the Benefits at a Glance page.

•

Prescription •

Stretch Your Benefit Dollars This benefit plan offers you and your family savings for medical care through discounts negotiated with providers and facilities in the First Health Network. Choosing an innetwork provider helps maximize benefits. When you use an in-network provider, you will automatically receive the network discount and the doctor's office will file the claim for you. If you use a doctor who is not part of the network, you will not receive the discount and you may need to file the claim yourself.

First Health Network 1-800-226-5116 www.firsthealth.com

Caremark 1-888-963-7290 www.caremark.com

Vision •

EyeMed Vision Care 1-866-559-5252 www.eyemedvisioncare.com

Dental •

DenteMax 1-800-752-1547 www.dentemax.com

How Do I Locate a Doctor? Enrolled members are encouraged to visit providers in the networks listed in order to maximize their benefit dollars. To find a participating provider or verify your current medical provider is in-network, please call or visit the network websites referenced on this page.

Do not contact the above Networks for questions regarding your medical benefits. All medical benefit questions should be directed to the Essential StaffCARE Member Services line at 1-866-798-0803.

What if I need to have a prescription filled? For generic and brand prescriptions , the plan pays you $20 per day up to the annual maxi mum, for drugs dispensed by a pharmacist. Prescription drug coverage is not provided for drugs administered during a physician office visit or hospital stay. If you choose a participating pharmacy and present your ID card , you will receive a discount off the retail price of the prescription at the time of purchase. Save your receipt to file a claim for reimbursement of the fi xed dollar amount.

Do I have to go to an in-network provider? Tt is not required that you go to an in-network provider. If you choose a provider who partici pates in the PPO network , you recei ve two key advantages: •

PPO discount for all services.

•

The provider will file the claim to the plan.

When should I expect an ID card? ID cards will be mailed as soon as your enrollment form is received and processed . You should receive your ID card within 10 business days of your effective date.

Member ID Cards An ID card and confirmation of coverage letter will be mailed to your home address . If you do not receive these documents within 10 business days of your effective date, or have a change of address , please contact the Essential StaffCARE Customer Service at 1-866-798-0803. Present your ID card to the provider at the time of service. These ID cards are used for identification purposes and providers use them to verify eligibility status .

Pnlic~

BENEFITS AT A GLANCE

Annual Outpatient Maximum

$300perday

Physician Office Visit

$100 per day

$400perday

Diagnostic Lab

$75 per day

$2,000 per day

Diagnostic X-ray

$200 per day

Daily Standard Care Maximum 2

Surgery

$400 per day

Anesthesiology

SJdlled Nursing payable for stays in a skilled nursing facility after a hospital stay

!

!-

Coverage B !

-

-

·

3 months

$200 per day

Emergency Room - Accident

$500 per day

Outpatient Surgery

$500perday

·50·%--

__ ____1:il!i_~¥~ ·