2016 BENEFITS ELECTION FORM

2016 BENEFITS ELECTION FORM
Banner ID: Ex. (M00012345) M 0
0
0
New Hire
Date of Hire
Last Name:
First Name:
SSN
Gender
Address:
M.I.
Contact Number
Marital Status:
DOB:
Status Change
City
State
Zip Code
You must make an election for each benefit (even if declining coverage). All rates are effective January 1, 2016.
1. MEDICAL: UnitedHealthcare (Choose one option below): All rates are Bi-Weekly
Basic Option
Employee Only
$29.13
High Option
Employee + Spouse
$126.96
Employee + Child(ren)
$85.20
Employee + Family
$185.31
Employee Only
$53.62
Employee + Spouse
$196.32
Employee + Child(ren)
$146.39
Employee + Family
$286.55
DECLINE MEDICAL COVERAGE (If selected, please complete Employee Declination Acknowledgement on page 3)
2. DENTAL: UnitedHealthcare
(Choose one option below):
Employee Only
$1.93
DECLINE DENTAL COVERAGE
Employee + Spouse
$7.71
3. VISION: UnitedHealthcare
(Choose one option below):
Employee Only
$0.27
Employee + Child(ren)
$5.82
Employee + Family
$12.33
DECLINE VISION COVERAGE
Employee + Spouse
$0.99
Employee + Child(ren)
$0.75
Employee + Family
$1.58
Required Dependent Information (ONLY If Enrolling Dependent(s) in Medical, Dental and Vision Coverage.)
Social Security Numbers are legally required for covered dependents by the Centers for Medicare and Medicaid Services.
Relationship
Name:
DOB:
SSN:
Gender:
Name:
DOB:
SSN:
Gender:
Name:
DOB:
SSN:
Gender:
Name:
DOB:
SSN:
Gender:
Name:
DOB:
SSN:
Gender:
Additional Dependents
Please add First Name, Last Name, DOB, SSN, Gender, and Relationship.
Please add one dependent per line.
Additional Dependents:
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4. BASIC LIFE & AD&D: Basic Life is 2x your base annual salary up to $500,000. This coverage is provided to you at no cost. You must
designate a beneficiary. SSN# is needed to locate beneficiary. If beneficiary is living outside of the U.S. please provide a full address.
Beneficiary
Name
Relationship
SSN
%
Address
(if outside the U.S. ONLY)
%
%
%
%
%
Beneficiary Total (Must Equal 100%)
%
5. EMPLOYEE SUPPLEMENTAL LIFE: You may purchase up to 1x your base annual salary up to $500,000. A Statement of Health
will be required for amounts over $200,000. Beneficiary for Supplemental Life will be the same as Basic Life unless noted otherwise.
Enroll
Decline Coverage
6. EMPLOYEE SUPPLEMENTAL AD&D: You may purchase up to 1x your base annual salary up to $500,000.
Enroll
Decline Coverage
7. SUPPLEMENTAL SPOUSE LIFE: There must be an election for the Employee Supplemental Life in order to purchase coverage
for a spouse. Choose life insurance for your spouse in units of $5,000 up to a maximum of $150,000 (cannot exceed 50% of the
employee's base annual salary). A Statement of Health will be required for amounts over $50,000.
Enroll
Decline Coverage
Benefit Amount
Spouse Name:
DOB:
SSN:
Gender:
8. SUPPLEMENTAL DEPENDENT CHILD LIFE: There must be an election for the Employee Supplemental Life in order to purchase coverage
for a dependent child. Choose life insurance for your dependent children in units of $2,500 up to a maximum of $10,000. Amount must be equal per child. (i.e. $10,000
Enroll
Decline Coverage
Benefit Amount
Child:
DOB:
SSN:
Gender:
Child:
DOB:
SSN:
Gender:
Child:
DOB:
SSN:
Gender:
Child:
DOB:
SSN:
Gender:
Child:
DOB:
SSN:
Gender:
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9. SHORT TERM DISABILITY:
Enroll
Decline Coverage
10. FLEXIBLE SPENDING ACCOUNT (FSA): Elect to participate in the Flexible Spending Account plan for the current calendar year. You can
contribute to your Health Care Account and to your Dependent Care Account each calendar year.
Enroll
Decline Coverage
Health Care Contribution (Annual Limits: Min. $200, Max $2,550):
Health Care Contribution:
Per Pay Period Amount:
$0.00
Dependent Care Contribution (Annual Limits: Min $200, Max $5,000):
Dependent Care Contribution:
Per Pay Period Amount:
$0.00
By default, United Healthcare will make Automatic Reimbursement payments from your Health Care FSA for expenses submitted to, but not payable
by, your medical plan. Expenses will be automatically reimbursed through your FSA and will be incurred by you (and/or your spouse and/or your
eligible dependents) and will not be reimbursed by another plan. You cannot use the expenses reimbursed through the FSA program as deductions or
credits when filing your individual income tax return. To opt out of Automatic Reimbursement visit www.myuhc.com.
Acknowledgement/Signature
I certify that I have read the benefits PowerPoint summary and understand the benefits for which I am enrolling. I hereby authorize
my employer to make applicable changes, as noted above, to my current benefit elections and to deduct from my salary, under the Section
125 premium conversion, in the amount necessary to pay for the coverage(s) elected on this form. Such elections will remain in effect and
cannot be changed during the plan year, unless the change is due to and consistent with a change in family status.
Employee Signature:
Date:
Typing your name serves as your signature
**ONLY Complete Below if Declining Medical Coverage**
EMPLOYEE DECLINATION ACKNOWLEDGEMENT
If you wish to decline coverage for yourself and/or your dependents, you must sign below and provide a reason for declining coverage for
yourself and any dependents.
Coverage under another employer's medical plan:
Employer Name:
Plan Name:
Plan #:
Other reason(s):
Employee Signature:
Date:
Typing your name serves as your signature
I acknowledge that I have been given the opportunity to enroll myself and/or eligible dependents in my employer's medical (including
dental and vision) plan(s). I am declining to enroll myself and/or eligible dependents in all or some of the stated plans.
Submit
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This worksheet is for informational purposes
Basic Life and Basic AD&D
Provided at no cost to you.
Employee Supplemental Life
$.30 per $1,000 of coverage
Supplemental Spouse Life
$.30 per $1,000 of coverage
Supplemental Child(ren) Life
$.20 per $1,000 of coverage
Employee Supplemental AD&D
$0.025 per $1,000 of coverage
Short-Term Disability (STD)
$0.24 per $10 of weekly covered benefit
Long-Term Disability (LTD)
Provided at no cost to you.
Enter Annual Salary:
Premium Calculation Examples:
Employee Supplemental Life
$0.00
Premium Calculation Worksheet:
Employee Supplemental Life and Supplemental Spouse Life
Example: Employee earning $45,200 per year elects
Supplemental Life of 1 times earnings. Earnings are rounded to
$0.00 / 1000 =
$0.00 per mo.
$0.00
per month X 12 months =
$0.00 per year
$0.00
per year / 26 pay periods =
$0.00
the next higher $1,000 multiple ($46,000 in this example).
X $0.30
$46,000 x $0.30 = $13,800 ÷ $1,000 = $13.80 per month
($13.80 x 12 months) = $165.60/yr.
$165.60/yr. ÷ 26 pay periods = $6.37 bi-weekly
Supplemental Spouse Life
There must be an election for the Employee Supplemental
Life in order to purchase coverage for a spouse.
Example: Employee enrolls spouse in the Supplemental Spouse
Life plan at the $20,000 coverage level.
$0.00 bi-weekly
*Note: The calculations are the same for Employee Supplemental Life and
Supplemental Spouse Life.
Employee Supplemental Life: $500,000 Maximum
Supplemental Spouse Life:
$150,000 Maximum
$20,000 x $0.30 = $6,000 ÷ $1,000 = $6.00 per month
($6.00 x 12 months) = $72.00/yr.
$72.00/yr. ÷ 26 pay periods = $2.77 bi-weekly
Employee Supplemental AD&D
Employee Supplemental AD&D
Example: Employee elects Supplemental AD&D. Coverage
$0.00 / 1000 =
$0.00 per mo.
$0.00
per month X 12 months =
$0.00 per year
$0.00
per year / 26 pay periods =
$0.00
matches the Supplemental Life coverage of $46,000.
$46,000 x $0.025 = $1,150 ÷ $1,000 = $1.15 per month
X $0.025 =
($1.15 x 12 months) = $13.80/yr.
$13.80/yr. ÷ 26 pay periods = $.53 bi-weekly
*Note: Employee Supplemental AD&D: $500,000 Maximum
Page 4 of 5
$0.00 bi-weekly
Supplemental Child(ren) Life
There must be an election for the Employee Supplemental
Life in order to purchase coverage for a dependent child.
Supplemental Child(ren) Life
$10,000.00 X $0.20 =
Example: Employee enrolls his 3 children in the Supplemental
$2.00
Child Life plan at the $10,000 coverage level (for each child).
$2,000.00 / 1000 =
$2.00 per mo.
per month X 12 months =
$24.00 per year
Premium is based on coverage level, not the aggregate of the
$24.00
children's coverage.
per year / 26 pay periods =
$0.92 bi-weekly
$10,000 x $0.20 = $2,000 ÷ $1,000 = $2.00 per month
($2.00 x 12 months) = $24/yr.
$24/yr. ÷ 26 pay periods = $.92 bi-weekly covers all 3 children
at $10,000 of coverage for each child
Short-Term Disability (STD)
Short-Term Disability (STD)
Example: Employee earning $45,200 ( $869.23 per week)
$0.00
elects STD coverage. The maximum weekly benefit is 60% of
weekly earnings up to $2,500 per week. In this example, the
$0.00
STD benefit is $521.54 per week (60% of $869.23)
/ 52 weeks =
X .60 =
$0.00
weekly earnings
$0.00 maximum weekly benefit
$521.54 x $0.24 = $125.17 ÷ $10 = $12.52 per month
$0.00
($12.52 x 12 months) = $150.24/yr.
X $0.24 =
$0.00
/ $10 =
$0.00 per mo.
$150.24/yr ÷26 pay periods = $5.78 bi-weekly
$0.00
X 12 months =
$0.00
$0.00
per year / 26 pay periods =
$0.00
*Note: Maximum is up to $2,500 per week.
Page 5 of 5
per year
bi-weekly