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EMPLOYEEINFORMATION
LastName: / FirstName: / Middle: / SocialSecurity#:
Maritalstatus
Single Married / Birthdate: / Age: / Gender:
MF / Phone#:
Streetaddress: / City: / State: / ZIPCode:
Hiredate: / JobTitle / Email: / Effective Date(For HR Use Only)
EnrollmentReason:
NewHire Rehire Open Enrollment ChangeinFamilyStatus/LossofCoverage:
Update Personal Information Terminate Coverage
Ifyouare WAIVINGanycoverage,Pleasecompleteandsignthelastpageofthisapplication.
Payroll Deduction is taken out on a pre-tax basis as listed before per your election.
MEDICAL INSURANCE
HMO Plan / Bi-weeklyPayroll Deduction / PPO Plan (CA) / Bi-weeklyPayroll Deduction / H.S.A PPO Plan / Bi-weeklyPayroll Deduction
EmployeeOnly / $18.62 / EmployeeOnly / $34.35 / EmployeeOnly / $1.09
Employee+ Spouse / $74.94 / Employee+ Spouse / $114.07 / Employee+ Spouse / $43.85
Employee+ Child(ren) / $55.77 / Employee+ Child(ren) / $95.75 / Employee+ Child(ren) / $27.37
Employee+ Family / $159.59 / Employee+ Family / $224.09 / Employee+ Family / $112.56
DENTAL / VISION INSURANCE
DENTAL PPO Plan / Bi-weeklyPayroll Deduction / DENTAL DHMO Plan / Bi-weeklyPayroll Deduction / VISION Plan / Bi-weeklyPayroll Deduction
EmployeeOnly / $2.94 / EmployeeOnly / $1.29 / EmployeeOnly / $0.63
Employee+ Spouse / $8.85 / Employee+ Spouse / $3.79 / Employee+ Spouse / $1.79
Employee+ Child(ren) / $9.94 / Employee+ Child(ren) / $3.23 / Employee+ Child(ren) / $1.89
Employee+ Family / $20.95 / Employee+ Family / $6.66 / Employee+ Family / $3.70
DEPENDENTINFORMATION–ONLYCOMPLETEIFYOUARECOVERINGASPOUSEORCHILD
Fill out ONLY if elect HMO/DHMO Plan
Med HMO PCP
or Code / DHMO PCD or Code
Relationship
Spouse / LastName: / First: / MI: / Birthdate: / Gender
M F / SSN#
Relationship
Child / LastName: / First: / MI: / Birthdate: / Gender
M F / SSN#
Relationship
Child / LastName: / First: / MI: / Birthdate: / Gender
M F / SSN#
Relationship
Child / LastName: / First: / MI: / Birthdate: / Gender
M F / SSN#
Relationship
Child / LastName: / First: / MI: / Birthdate: / Gender
M F / SSN#
AETNA OPTIONAL LIFE & AD&D INSURANCE
Check one box only. Please refer to Aetna plan information for detailed cost information
Employee / Coverage Option / You must be enrolled to cover your dependents
Accept Coverage / 5x Annual Salary, up to a maximum of $500,000, in $10,000 Increment
Decline Coverage / Guarantee Issue Amount of $200,000 (under age 60) – new hires within 30 days
$ ______Elected Amount
Spouse / Coverage Option
Accept Coverage / Must not exceed 50% of employee election or $100,000
Decline Coverage / Guarantee Issue Amount $30,000 (under age 60) – new hires within 30 days
$ ______Elected Amount
Child(ren) / Coverage Option
Accept Coverage / $5,000 $10,000
Decline Coverage
Name Your Life Insurance Beneficiaries / Primary beneficiaries must total 100%
Primary Beneficiary 1: First, Middle, Last Name / Relationship to Employee / Percent
%
Primary Beneficiary 2
%
Contingent Beneficiary
%
In the event of the designated primary beneficiaries are deceased, the contingent beneficiary will receive the benefit.
AETNA LIFE/AD&D AND DISABILITY INSURANCE
AUTO ENROLLED / Short Term Disability Weekly Benefit = 60% of your base salary up to $1,000 weekly maximum
(Approved disability benefits begin after 15 day elimination period) 100% Paid for by Company
Long Term Disability Monthly Benefit = 60% of your base salary up to $5,000 monthly maximum
(Approved disability benefits begin after 90 day elimination period) 100% Paid for by Company
Life/Accidental Death & Dismemberment = 1x annual salary, minimum $20,000, maximum $50,000
100% Paid for by Company

DECLINATION / WAIVER of COVERAGE

By signing below, I acknowledge that the coverage available to me has been explained by my employer and that I knowingly have elected not to enroll in the coverage offered, either for myself or my eligible dependents, for the reason listed below.

I decline coverage for: (Check ALL that apply)

Medical / Dental / Vision
Myself
Spouse
Child(ren)

Reason for declining coverage: (Check one)

Covered by spouse’s group coverageCarrier name and ID#:

Covered by Medicare

Enrolled in other insurance plan Carrier name and ID#:

Other (Explain)

Employee Signature Date

(Sign ONLY if you are declining coverage for yourself or eligible dependents)

Health Care Reform – beginning in 2014, the Affordable Care Acts includes a mandate for most individuals to have health insurance or potentially pay a penalty for non-compliance. As your employer, we would like to remind you of this new provision to ensure that if you are waiving and/or declining coverage for yourself or your eligible dependents, that they do carry the required minimum essential coverage through other resources. If you reside in the State of California, you can visit for for government programs. If you reside outside of California, you can go to the government site for more information.

If you acquire a new dependent or involuntary lose coverage during the year, with proof of the qualifying event, you may re-enroll under the company plan within 31 days of such event. Otherwise, I understand that by declining coverage, I may not be enrolled myself and/or my eligible dependents in my employer’s health plan until the next Open Enrollment.

I understand, agree, and represent that I have reviewed the plan coverage offering by the company and understand the rights to my coverage election.

Employee Signature Date

(Sign ONLY if you are declining coverage for yourself or eligible dependents)

Sign BelowToEnroll In CompanyBenefits:

Icertifythatthestatementsonthisapplicationandallinformationfurnishedbymearetrueandcompletetothebestofmyknowledge.Iauthorizeanyhealth careprovider todisclosetoAetna,oritsdesignatedagent,anyinformationacquiredinconnectionwithmypastorfuturecareortreatmentorthatofany dependentnamedhereinorhereafteraddedtomycoverage.Iunderstandthatnorightwhatsoeveriscreatedbythisapplicationandthatthe sameshallnotbeconsidered acceptedunless anduntil thecontract is actuallyissuedby Aetna.IfI applyfor a managedcare option, I (we)fullyunderstandthat in order toreceive thePreferredLevelofBenefitsmy(our)PrimaryPhysician(s)mustprovideorpreauthorizeallmedicalandhospitalcare,exceptinlifethreateningemergencieswhileaway fromhomeandas specified in my(our)Certificate or Outline ofCoverage.

Iherebyapplyforthecoveragenowbeingofferedtomyselfanddependent(s),ifany,as shownonthisform.Myemployerisauthorizedtodeducttheappropriateamountsfrommyearnings,asauthorizedunderIRSSection125.Iunderstandthatanypre-taxamountswillnotbesubjecttoSocialSecurityorfederalincometaxwithholding,whichmay result inareduction offutureSocial Security benefits towhichI may be entitled. Ihereby declarethat allentries onthefront andrear ofthis formaretrueandcomplete andthatanymaterialmisstatementsorfailuretoreportinformationmaybeusedasthebasisforrecessionofcoverageformeandmydependent(s)(ifany)fromthe effectivedate.Iunderstandthatthe insuranceselectedwillbeginontheeffectivedate.IfIamnotactivelyatwork,ormydependentsarenotactivelyatwork,ortheyare unableto engage inalltheusualduties ofaperson of like ageandsex, theeffectivedate ofanynon-healthcoveragewill bedelayeduntil theindividual returns towork, or the dependentresumesusualduties.IfIamnotactivelyatwork,theeffectivedateofhealthcoveragewillbedelayeduntilIreturntowork,unlessIamnotactivelyatworkdue toahealth condition. Iauthorizeanyhealthcare professionalorentityto giveAetnaoranyoftheirdesignees,anyandallrecordsorinformation pertainingtothe medicalhistoryor servicesrenderedtousforanyadministrativepurpose,includingevaluationofanapplicationor claim,andforanyanalytical orresearch purposes.Ialsoauthorize,onbehalfofmyselfandanydependents,theuseofaSocialSecurityNumberforpurposeofidentification.Aphotographiccopyofthis authorizationshall be validas theoriginal.

IfIamcurrentlynotenrolledinbenefitsofferedonthisformanddonotcompleteandsubmitanenrollmentformunderthemedicaldental,and/orvisionplan(s)onorbeforethedatespecifiedbythePlanAdministrator,Ishallbedeemedtohaveelectednottohavecoverageforthenextplanyearandwillnotbeeligibletoenrolluntilthe next annual enrollment periodunless achange instatus or specialenrollment period occurs.

ImportantNotice:ThePlanisdesignedtoonlypaycoveredexpensesforwhichpaymentisnotavailablefromanothersource,includinganyinsurancecompanyoranotherhealthplan. ByenrollinginthePlan,youandallyourcovereddependents(ifany)becomesubjecttothetermsandconditionsunderthe AetnaCertificateofCoverage, includingthesectionentitled,Subrogation. ThatsectionexplainsthePlan'srightstorecovercertainpaymentsthatithasmaderelatingtomedicalexpensesthatareormay betheresponsibilityofathirdparty(suchas,but notlimitedto,expensesincurredfollowinganautomobileaccident),andhow suchrightsmayaffectanyrights you(or your representative)may havetorecoverinjury-relatedexpensesorawardsfromanotherparty,andwithrespecttoanyresultingproceeds. Pleaserefertothe AetnaCertificateof Coveragefor further details.

ImportantNotice:Ifyourefusecoverageforyourself,youautomaticallyrefusecoverageforanydependents.Ifyouaredecliningenrollmentforyourselfandyourdependents(includingspouse)becauseofotherhealthinsurancecoverage,youmayinthefuturebeabletoenrollyourselforyourdependentsinthisplan,providedyou requestenrollmentwithin30daysafteryourother coverageends.Also youmustindicatethereasonfordecliningenrollment.Ifyouhavea status changeevent,new dependentasaresultofamarriage,birth,adoption,youmaybeabletoenrollyourselfandyourdependentsprovidedyourequestenrollmentwithin30daysafterthe marriage, birth, or adoption.

Iunderstand,agree,andrepresent thatIhavereadthisdocument orithasbeenreadtomeandthattheanswersprovidedwithinthisentireapplicationfor coverage aretothebestofmyknowledgeandbelief,trueandcomplete. Iunderstand thatifanyintentionalmaterialfalsestatement,misrepresentation,or omissioniscontained within,mycoverage couldbereduced, deniedof,orvoided. Ifurtherauthorize myemployer todeductfrommyearnings the contributions(if any)electedaboveona pre-taxbasis.

Employee Signature Date

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