DRT Shared Benefit Enrollment Form

Please enter your Employee ID number below. This number can be found within your New Hire Benefits Packet.

As a note, you will need identifying information (i.e., date of birth, social security number, etc.) for yourself and any covered dependents in order to complete this form.

Enter your Employee ID

Please fill out the form below as accurately as possible. You may view or download a copy of the Benefits Guide in the Insurance Information section of the Enrollment form located below.

If you are re-enrolling in coverage, this form is defaulted to the elections you currently have. Click on each field for more options.

Basic Information

Mailing Information

Contact Information

This information is for internal use only. One phone number is required and will be used by our benefits team to contact you with any questions related to your enrollment. Your email address will be used to send a confirmation email at the end of this enrollment, as well as to provide updates during the enrollment process.

Dependent Information

Dependent information must be entered if you are electing any of the below coverage options for an eligible dependent. Be sure you have your dependent(s) date of birth and social security number readily available for any new dependent(s). Please only enter accurate information to ensure the dependent(s) are enrolled in coverage correctly.

Insurance Information

Click here to review the Benefits Enrollment Guide.

Medical Insurance

Since you have elected Employee + 1 Child, you will be required to tell us which child listed you would like to elect coverage for.

HSA Deposits

Per pay period, how much would you like us to withhold to be deposited into your tax-free HSA account? If you are over age 65 and on Medicare Part B you are not eligible to contribute to an HSA account.

Waiver of Health Insurance Coverage

The company requires that all full-time employees participate in the company health insurance plan. This waiver is for employees who have verifiable ACA accredited coverage. Examples of ACA accredited coverage include, but are not limited to: group coverage sponsored by a spouse or parent, Tricare, Medicare, VA Healthcare, etc.

A waiver of health insurance coverage is granted only when you complete the below waiver information and submit proof of other coverage to the HR Department. Coverage that is not ACA accredited will not be accepted as a valid waiver of health insurance coverage.

If you elect Medical coverage, Dental and Vision coverage can be added for no additional cost for up to the same level of coverage. You will still need to make your Dental and Vision elections below to indicate what level of coverage you would like. If you are waiving Medical coverage, you can add Dental and Vision coverage at the rates listed below.

Dental Insurance

Vision Insurance

Voluntary Disability

Short Term Disability

Short Term Disability

Long Term Disability

Dependent Life Insurance

You will be enrolled in employer-paid life insurance coverage in the amount of $40,000 on you. This also provides an optional $10,000 on your spouse and $5,000 on your children for the rate listed below. This includes an equal amount of accidental death and dismemberment coverage.

Voluntary Life

In order for your spouse and child(ren) to be covered, you must elect coverage.

Evidence of Insurability (EOI) is required to increase:
Employee amount in excess of $200,000
Spouse amount in excess of $50,000
Child amount in excess of $15,000

Beneficiaries

Please note: As a non-driver you will be required to enter beneficiary information. Please refer to your Enrollment Guide for more details.
Please note: Because of your company-paid life insurance benefit, you will be required to enter beneficiary information. Please refer to your Enrollment Guide for more details.
Please enter the full name of all required beneficiaries.

Spouse Beneficiary:

Child Beneficiary:

Accident Insurance

Critical Illness Insurance

Cancer Insurance

Hospital Indemnity Insurance

401K

Did you know DRT Shared offers enrollment to a 401K through Fidelity? Go to www.netbenefits.com to enroll or change your contributions.

Final Agreement

I understand that the information contained in this website is a summary of the benefit plans offered by the Company. I understand that the operation of the Plan, including events making me eligible for benefits, the amount of benefits to which I (or my beneficiaries) may be entitled, and actions I (or my beneficiaries) must take to request and support a claim for benefits will be governed solely by the terms of the official Plan document. To the extent that any of the information contained on this website or any information I receive orally is inconsistent with the official Plan document, I agree that the provisions set forth in the Plan document will govern in all cases. I understand that if I wish to review a Plan document, I should request a copy from the Company’s Human Resources Department.

Unless I experience a qualifying life event (for example, marriage, divorce, birth or adoption of a child, among others) that would permit a mid-year election change, I understand that I cannot change my benefit elections during the plan year. If I do experience a qualifying life event, I have no more than 30 days from the date of the event to make a new election.

By enrolling in one or more of the benefits plans, I authorize the Company to make payroll deductions for the pre-tax and after-tax coverage(s) that I have elected. During the course of my employment, there may be a time that my insurance premium deductions may not be processed due to a leave of absence, partial paycheck, or another reason. I understand this may result in the Company incurring expenses associated with paying my portion of the insurance premiums. I understand that I will need to work with the company to recover these expenses through additional payroll deductions or by payments made directly to the Company until the Company is fully reimbursed.

For Long Term and Short Term Disability Plans and Life Insurance Plans, I acknowledge that eligibility ultimately may depend upon my completing, and the insurance company accepting, an Evidence of Insurability (EOI) document. I understand that if my elections require an EOI, the coverage will not be effective until the 1st of the month following the approval of my EOI. I understand that my decision to decline medical insurance will not be accepted until proof of ACA accredited health insurance coverage is received and approved.

I declare under the penalty of perjury that all information I am submitting is true, accurate, and complete.

Please type your name below then use your mouse or finger to sign your name. Once complete, click the blue bar below to submit your enrollment form. You will receive confirmation to the email address on file indicating your enrollment form was received.