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Prorated Annual Fee & Initiation Fee

$350.00

Prorated Annual Fee & Initiation Fee quantity

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Guardian Independent Operator Association

855-606-3726

© 2022 Guardian Independent Operator Association

Step 1 of 2

50%

Would you like your 2022 Strategy to be the same as your 2021 Strategy?(Required)

Yes

No, I have changes to make.

Please click the Submit button below to be redirected to your 2022 Strategy Selection & Change Form. Thank you.

Consent(Required)

Owner/Operator Consent to Maintain Strategy Selections for 2022

By clicking "I agree" below, I certify the following on behalf of my Chick-fil-A franchised business.

1. For the 2022 GIOA Plan Year, I am confirming, as a dues-paying member of GIOA, that I will be keeping my 2021 Strategy in place with no changes. This confirmation of Strategy authorizes GIOA to maintain my current waiting period and contribution levels for each of my team members.

2. For 2022, I also confirm and understand that all benefits offered by GIOA will be offered to my team members on a post-tax payroll deduction basis as outlined below.

The 2022 GIOA Packaged Benefits Offering:

• Anthem Medical - 5 plans options to select from for the Full-time team members
• Anthem Dental - 2 plan options Low & High option for all whether FT or PT
• Anthem Vision - 2 plan options Low & High option for all whether FT or PT
• Life & Disability coverage options at varying levels
• Supplemental Benefits such as Critical Illness, Accident & Hospital Indemnity
• (MEC) Minimum Essential Coverage plan for part-time team members
• Employee Assistance Program is moving to Anthem & will be made available to all benefit-eligible employees starting January 1st, 2022
** Should any plan design changes be applicable to my current selections or the plan offer is no longer available, the closest plan measured by similar benefits shall be substituted.

3. I have carefully reviewed my strategy, the benefits information, rates, contribution requirements, and rules presented in the 2022 GIOA Strategy Guide & Open Enrollment Preview booklet provided and understand it is to my discretion what I contribute towards the cost of medical coverage for my team members.

4. I understand that neither GIOA, UnifyHR, Mercer, or any other service provider is responsible for determining whether my contributions to health care premium meets ACA affordability guidelines.

5. I understand I can confirm my current applicable large employer “ALE” status by accessing my account information via UnifyHR directly through the online portal, https://unifyhr-1.hubspotpagebuilder.com/gioaacasupport , or by single sign-on (SSO) through the iNGAGED app. I should use this information to project my ALE standing for 2022. If my ALE status changes at year-end, I will not be able to update my strategy after the Operator strategy period has ended.

6. I agree that each of my selections reflects my commitment for 2022 with respect to the Plan and agree to be bound by those selections and the terms of the Plan

7. I understand this Commitment Form may be delivered, communicated, received, and stored by electronic means and an electronic record of same shall be deemed to have the same legal effect as an ink-signed executed Commitment Form for all purposes.

I have reviewed the points of agreement above and do hereby confirm my strategy selections with no changes, subject to the provisions above.

I agree.

Have you experienced one of the below qualifying changes?*
Store(s) state location:*

2021 Job Title Change

Step 1 of 6

16%

Changes made in the Chick-fil-A payroll system will impact 2020 contributions and deductions. Therefore, any changes to Team Member job titles that will be effective in 2021 must be handled with a manual load to the Benefitfocus enrollment system so as not to impact 2020.

Complete the following table for any Team Members who will have a job title change in 2021. This information will be loaded into the Benefitfocus enrollment system so that Team Members see the correct Operator contributions and coverage cost for 2021 during Annual Enrollment.

In January 2021, you will need to enter the new Job Title in the CFA payroll.

Changes made after 1pm Nov 2nd will only apply to Operators who are participating in the second OE period of 12/07-12/17.
Operator ID#*
How Many Employees Need Updating?*
Employee ID#*
EE Name*
First Last
Current Job Title*
2021 Job Title*

Employee 2 ID#*
EE 2 Name*
First Last
Current Job Title*
2021 Job Title*

Employee 3 ID#*
EE 3 Name*
First Last
Current Job Title*
2021 Job Title*

Employee 4 ID#*
EE 4 Name*
First Last
Current Job Title*
2021 Job Title*

Employee 5 ID#*
EE 5 Name*
First Last
Current Job Title*
2021 Job Title*

After clicking submit, we will update your information within the system. If you have additional changes, you can submit another form at any time. Thank you.