JQ Associates Elections | Quick Simple Onboarding

DO NOT COMPLETE IF: you have not been employed with JQ Staffing for at least one full year. You are eligible if you have been employed for ONE full year and worked at least 30 hours per week.

IF ELIGIBLE: This insurance REQUIRES you to pay 9.12% of your gross income / paycheck towards the cost of the insurance.

Also, the insurance is prepaid so you MUST give notice if you plan on ending your employment with JQ Staffing. Any prepaid premiums will be withheld from your final paycheck, and any refunds will be issued by the insurance company directly to you.

Name *

First

Last

Social Security Number *

Address *

Address Line 1

City

State

Zip Code

Date of Birth *

Email *

Phone Number *

Legal Gender *

Female
Male

Date of Hire *

Type of Change

Health Insurance *

If you are currently enrolled and you select "Waive" you will be REMOVED from the insurance

Primary Physician

Your Physician's name

Cigarette Smoker? *

Yes
No

Insurance Start / Effective Date *

Please choose the date the insurance "turn on" / go into effect. Effective dates can ONLY be on the first day of the month (i.e. No mid-month effective dates).

2023 Bronze Summary

2023 Bronze Monthly Price

Terms of Agreement & YOUR PAYMENT *

I understand that I will pay 9.12% of my income towards the cost of my health insurance for myself. I also understand dependents / family members are not eligible to participate in the JQ Staffing ICHRA plan. I understand that if I am a "smoker", that I will be responsible for paying any additional premiums added for being a smoker. I understand my portion of the premium payment will be collected via Payroll Deduction from my paycheck. I am responsible for paying for the insurance and submitting proof of payment to be reimbursed for amounts beyond 9.12% of my income.

YOU ARE AGREEING TO PAY 9.12% of your income towards the cost of the health insurance!

Also, the insurance is prepaid so you MUST give notice if you plan on ending your employment with JQ Staffing. Any prepaid premiums will be withheld from your final paycheck, and any refunds will be issued by the insurance company directly to you.

Notes

Signature *