Application/Enrollment Checklist
- _____ Completed/Signed Original Applications, for each eligible employee, for each coverage in which they are enrolling (medical, dental, etc.).
- _____ Completed/signed, Coverage Declination form for each employee declining coverage for themselves and/or their dependents, for each coverage that applies.
- _____ Complete/signed Employers Request for Participation Agreement and Election of Benefits.
- _____ Copy of latest DE6. Indicate those employees not eligible for coverage and reason. If you do not have employees, please write a note to that effect.
- _____A check for the first month's premium for all coverages selected. Make check payable to: BUILDERS EXCHANGE SERVICE ASSOCIATION (BESA) INSURANCE TRUST.
- _____ For PPO & POS applicants, you must complete "Other Health Insurance" Statement (Item #8 on Health Net application). Your benefits may be affected unless completed.
Submit all of the above to:
Builders Exchange Service Association
135 Camino Dorado
Napa, California 94558-0520
If you have any questions, call (707) 255-2690.
Note: Please review applications prior to submitting them
Incomplete applications may cause a delay in your enrollment to the following month. Be sure ALL applications are filled out completely (i.e., date of hire, social security numbers for employees and dependents, names of primary physicians and medical groups for all HMO enrollees, etc.)
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