2013 Guam Crew Insurance

Annual Enrollment Form

Page 1 of 4

INSTRUCTIONS: Review the information on What’s New for 2013 before making your choices on the form below.

Review the information on the 2013 Regional HMO Benefit Comparison chart before making your choices on the form below.

Complete the form and be sure to fill in your Employee # (the form cannot be processed without it). Return the form to the Hawaii Human Resources Department as soon as possible but no later than November 18, 2012.

This Annual Enrollment form allows you to change or cancel your Medical/Dental Insurance. Payment of insurance premiums will occur under the McDonald’s Premium Payment Plan. These choices must continue through December 31, 2013 unless you have a qualifying life event change. You will be able to make a new election effective January 1st of each year.

Employee Information / Last First Middle
Name: / EMPLOYEE #: ______
Your employee # can be found on the top right hand corner of your pay stub.
address: / home phone ( )
City: / State: / Zip code:
Indicate your choices (Bi-weekly Premium Rates) / GUAM (medical) EMPLOYEE ONLY EMPLOYEE + SPOUSE EMPLOYEE + DOMESTIC PARTNER
EMPLOYEE + CHILD(REN) FAMILY FAMILY WITH DOMESTIC PARTNER
NetCare Insurance – Employee Only Medical (54GM) $35.37 Employee Only
NetCare Insurance –Dependent Medical (54GM) $129.58 Employee + Spouse or Domestic Partner
$113.88 Employee + Child(ren)
$253.96 Family or Family with Domestic Partner
DECLINE COVERAGE
GUAM (DENTAL) EMPLOYEE ONLY EMPLOYEE + SPOUSE EMPLOYEE + DOMESTIC PARTNER
EMPLOYEE + CHILD(REN) FAMILY FAMILY WITH DOMESTIC PARTNER
 NetCare Insurance – Dental (54GD) $20.18 Employee Only $40.72 Employee + Spouse or Domestic Partner
$38.10 Employee + Child(ren) $56.04 Family or Family with Domestic Partner
 DECLINE COVERAGE
NOTE / NEW for 2013. You must also sign and submit the SURCHARGE AFFIDAVIT form or you will automatically have surcharges added to your premium. (Page 2)
Signature / I have reviewed the above insurance elections. Where I have not made an election or selected “decline coverage”, I have rejected coverage. I have until prior to the first day of the month that coverage could begin to make this election. After that date I understand that I will not be able to change the coverage elected or to enroll for any coverage until McDonald’s next Annual Enrollment period or within 31 days (60 days if the special event relates to CHIP or Medicaid coverage) of a qualifying life event change. At that time acceptance of the requested insurance change may depend on acceptance by an HMO/Dental HMO (DHMO). If applicable, I certify that this request is consistent with my life event change. I understand that I am responsible for paying each premium for the HMO/DHMO coverage I elect. I elect to pay my premiums, by payroll deductions under the McDonald’s premium payment plan for coverage that I elect. Failure to do so may result in termination of my coverage. I understand that, unless I change my election for a future year or because of a life event change, my insurance election on this form will remain in effect from year to year at the employee premium amounts announced by McDonald’s in the future.
Employee Signature: / Date:

SURCHARGE AFFIDAVITS for Annual enrollment

Employee Information / Last First Middle
Name: / Employee #: ______
**Your employee # can be found on the top right corner of your pay stub

Tobacco use

Complete only if ee elects medical coverage

TOBACCO USE AFFIDAVIT
Beginning in 2013, a tobacco use surcharge is being added to the medical premium for tobacco users. Complete the affidavit below to certify whether or not the surcharge should apply to you. IF YOU DO NOT COMPLETE THE AFFIDAVIT AND FINISH YOUR ANNUAL ENROLLMENT, YOU WILL AUTOMATICALLY PAY THE SURCHARGE if you’re enrolled in a McDonald’s medical plan for 2013. You will not be able to change this surcharge until annual enrollment for 2014.
Remember, use of a tobacco product means any use (even one time) of a tobacco product, including cigarettes, chewing tobacco, cigars, pipes or any other product that contains tobacco.
---- CERTIFICATION ------
By checking a box below, I agree that the statement I check is true and accurate to the best of my knowledge. I understand that if I am being purposefully dishonest, I could be subject to one or more of the following actions: I may be required to pay the surcharge for any months of the year that I didn’t pay it; my coverage may be terminated back to January 1, and I may be required to pay back all amounts that were paid from the medical plan on my behalf; and I may be subject to disciplinary action up to and including termination of my employment.
I certify …
r  I and all of my covered dependents have not used any tobacco products during the past 90 days or more, or have completed the medical plan’s smoking cessation program since August 1, 2012. (Surcharge does not apply.)
OR
r  I or at least one of my covered dependents have used a tobacco product within the past 90 days and have not completed the medical plan’s smoking cessation program since August 1, 2012. (Surcharge applies.)

Spouse coverage

Complete only if medical coverage category is ee+ spouse or DP, or family with spouse or DP

r  Click here if you are not covering a SP or DP

AFFIDAVIT REGARDING SPOUSE ACCESS TO OTHER COVERAGE
Beginning in 2013, a spousal surcharge is being added to the medical plan premium for employees whose covered spouse or domestic partner also has access to comprehensive medical coverage through his or her employer (other than McDonald’s). IF YOU DO NOT COMPLETE THE AFFIDAVIT AND FINISH YOUR ANNUAL ENROLLMENT, YOU WILL AUTOMATICALLY PAY THE SURCHARGE if you cover a spouse or domestic partner on your McDonald’s medical plan for 2013.Remember, comprehensive coverage means the insurance covers a wide variety of health care services (including doctor visits, hospital stays, surgery and rehabilitation) and has no lifetime dollar benefit limit, and has an annual dollar benefit limit of $2 million or more. Limited benefit plans and Medicare are not considered comprehensive coverage.
---- CERTIFICATION ------
By checking a box below, I agree that the statement I check is true and accurate to the best of my knowledge. I understand that if I am being purposefully dishonest, I could be subject to one or more of the following actions: I may be required to pay the surcharge for any months of the year that I didn’t pay it; my coverage may be terminated back to January 1, and I may be required to pay back all amounts that were paid from the medical plan on my behalf; and I may be subject to disciplinary action up to and including termination of my employment.
I certify …
r  My covered spouse or domestic partner does not have access to comprehensive medical coverage through his or her employer (or he/she is a McDonald’s staff or McOpCo restaurant employee). (No surcharge.)
OR
r  My covered spouse or domestic partner has access to comprehensive medical coverage through his or her employer (other than McDonald’s). (Surcharge applies.)

Surcharge Add from Mailer

What’s the extra cost?
The add-on premium cost is the same for tobacco use and spouse/domestic partner coverage. If both add-ons apply to you (you and/or a covered family member use tobacco and you cover a spouse/domestic partner who has access to another employer’s coverage), then the extra cost you pay each month is two times the number below.
For 2013, the surcharge for McDonalds PPOs and HMOs is:
Ø  $33 per month for Restaurant employees and Staff in the Associate and Coordination bands
Ø  $45 per month for Staff above the Coordination band
Ø  $58 per month for Officers
Take note: The add-on cost is only applied once for tobacco use, regardless of how many family members use tobacco.

Dependent Information Review and Update

(Guam Crew Annual Enrollment Form)

ImportantNotes / ·  Your dependents who should be on file with McDonald’s are defined as follows:
Spouse: Your spouse.
Domestic Partner: Your domestic partner who meets the eligibility criteria, and whom you wish to cover under your McDonald’s benefits. The criteria for eligibility are that you and your partner:
1.  Are in a mutually exclusive relationship, are each other’s sole domestic partner, have been so for at least six months and intend to remain so indefinitely;
2.  Are both at least 18 years of age (or at least age of consent in the state in which you live);
3.  Are both unmarried and have not been married within the last six months;
4.  Are not related closely enough by blood to bar marriage in the state in which you reside;
5.  Reside together in the same principal residence, have done so for at least the past six months and intend to do so indefinitely;
6.  Have joint responsibility for each other’s welfare and financial obligations and can upon request show certain required evidence of such responsibility.
Child: Your unmarried child under age 26 (older if handicapped and dependent on you for support) who is your natural child, adopted child, step child, foster child, or a child for whom you are the legal guardian. Children or dependents, such as grandchildren or parents, should not be listed even if they are your dependents for federal income tax purposes, except in the case of children for whom you are the legal guardian. These same rules apply for the child(ren) of your spouse or domestic partner.
·  Your dependents will not have coverage under McDonald’s medical, vision or dental plans in 2013 unless they are on file with McDonald’s.
·  If you are enrolling in an HMO or DHMO that you weren’t enrolled in for 2012, or adding or deleting dependents under HMO or DHMO coverage, you must complete the HMO/DHMO application form and forward that form to the Service Center.
·  The coverage category you elect for your 2013 benefits (such as Employee + Spouse) will determine which dependents are covered in 2013
·  If your dependent information changes at any time in the future, go online or call the Service Center to update it. If you have questions, call your Human Resources representative at (808)585-7127.
Follow these steps to update your dependent information / To update your dependent information online:
·  Go to the annual enrollment site at https://sco.mcd.com/enroll. You’ll need your EID and password, then the last four digits of your Social Security Number, to log on. Your EID is on your fact sheet. Your password is the one that was assigned to you, or that you designated. Watch for more information coming to your home about how to enroll and how to reset your password.
·  Click on the link to Review and update your dependent information.
To update your dependent information on this form:
·  Follow the instructions on page 4 of this form.
If you have Internet access, you should go online to update your dependents, and not send this form to the Service Center.
Employee Information / Last First Middle
Name: / EMPLOYEE #: ______
Your employee # can be found on the top right hand corner of your pay stub.

READ IMPORTANT NOTES FIRST.

Instructions

§  List dependent information below and send this form to the McDonald’s Service Center by mail or by faxing this page only to 630-623-5027.

§  You must include proof of age and dependency. Proof includes one of the following:

Ø  Birth Certificate, Hospital Certificate, Adoption and/or Legal Guardianship paperwork, Marriage Certificate.

How to update information using this form:

-  To add a dependent to your file, use the blank spaces to PRINT all information for any dependents*.

-  To delete a dependent from your file, contact your Human Resources representative at 808-585-7127.

Note: New Government rules require employers to collect Social Security numbers from dependents covered under health plans.

Dependent Information

CURRENT DEPENDENTS * / Please indicate: Yes or No / If child age 26 or older:*
Dependent Name
Last Name First Name Middle Init. / Social Security Number
/ Date of Birth
mm/dd/yyyy / Spouse, Domestic Partner** or Child* / Male or Female / Dental / Vision / Medical / Handicapped? Please indicate: Yes or No

Employee’s daytime phone number with area code: (_____) – _____ – ______

Signature / EMPLOYEE SIGNATURE: / DATE:

*See page 2 of this form for dependent (spouse, domestic partner or child) definitions.

**If you are adding a domestic partner, complete the Affidavit for Domestic Partnership / Dependent Tax Certification to (a) ensure coverage for your partner, and (b) certify any of your family members (domestic partner, eligible children) who are your dependents for federal income tax purposes. The Affidavit is available online through the annual enrollment web site or from the Service Center by calling (877) 623-1955. Completed Affidavit for Domestic Partnership / Dependent Tax Certification forms should be submitted to the Service Center during annual enrollment, and no later than 60 days of adding a Domestic Partner.

Please forward this completed form and all required attachments (if applicable) to:

Hawaii Human Resources Department FORM 3851A 11/1/12