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Rankin County School District – MetLife Cancer Enrollment
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Rankin County School District - MetLife Cancer
1) Plan Info
Plan Type
*
Add (Enroll)
Terminate
Change (change coverage or name)
Plan Name
*
Group Name
*
Group Number
*
Effective Date
*
2) Member Information
First Name
*
Middle Initial
Last Name
*
Gender
M
F
Social Security Number
*
Date of Birth (mm/dd/yyyy)
*
Email
Address
*
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U.S. Citizen
*
Yes
No
Contact Number
*
3) Plan Selection including Optional Elections/Riders
Variable Benefit Elections
Benefit
Option 1
Option 2
Option 3
Hospital Confinement
$100 per day
$100 per day
$100 per day
Surgical
up to $3,000
up to $4,500
up to $4,500
Radiation/Chemotherapy
$5,000 per month
$5,000 per month
$5,000 per month
Cancer or Specified Disease Diagnosis
$2,500
$5,000
$10,000
Colony Stimulating Factors
$4,000 per month
$4,000 per month
$4,000 per month
Wellness
$100 per year
$100 per year
$100 per year
Plan ( Required: You must select a plan option )
*
Select Plan
Option 1 - Employee ($24.01)
Option 1 - Employee + Spouse ($48.04)
Option 1 - Employee + Child(ren) ($33.59)
Option 1 - Employee + Family ($57.62)
Option 2 - Employee ($27.71)
Option 2 - Employee + Spouse ($55.39)
Option 2 - Employee + Children ($44.95)
Option 2 - Employee + Family ($65.92)
Option 3 - Employee ($33.06)
Option 3 - Employee + Spouse ($65.92)
Option 3 - Employee + Children ($44.95)
Option 3 - Employee + Family ($77.80)
Optional Intesive Care Rider
Option 1 - $325 per day
Option 2 - $625 per day
Option 3 - $825 per day
Select Rider Option
Employee - Option 1 ( $2.33 )
Employee + Spouse - Option 1 ( $4.97 )
Employee + Child(ren) - Option 1 ( $3.88 )
Family - Option 1 ( $6.52 )
Employee - Option 2 ( $4.47 )
Employee + Spouse - Option 2 ( $9.56 )
Employee + Child(ren) - Option 2 ( $7.45)
Family - Option 2 ( $12.54 )
Employee - Option 3 ( $5.90 )
Employee + Spouse - Option 4 ( $12.62)
Employee + Child(ren) - Option 2 ( $9.84)
Family - Option 3 ( $16.56 )
4) Add Dependents (Spouse and/or Children)
Action
Select Option
Add
Terminate
Change
Last Name, First Name, MI
*
Gender
Select Option
Male
Female
Dependent Social Security Number:
*
Email
Date of Birth (mm/dd/yyyy)
*
Relationship
*
Husband
Wife
Son/Stepson
Daughter/Stepdaughter
Other
Relationship
Child Handicap Status
Yes
No
Age when Handicap began:
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Your Signature (Type It)
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Date Signed
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Need Assistance?
Call (601) 957-3737
Plan Information
MetLife Cancer – Rankin Co Schools (PDF)
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