Section I: EMPLOYEE INFORMATION

Name: / SSN:
Date of Hire: / Daytime Phone:

Section II: DEPENDENTS

NAME /
Birth Date
/
Relationship*
/
SSN
/ Coverage Election
SpouseDom PartnerSonDaughter /
Med Dent Vis
SpouseDom PartnerSonDaughter /
Med Dent Vis
SpouseDom PartnerSonDaughter /
Med Dent Vis
SpouseDom PartnerSonDaughter /
Med Dent Vis
SpouseDom PartnerSonDaughter /
Med Dent Vis
SpouseDom PartnerSonDaughter /
Med Dent Vis
SpouseDom PartnerSonDaughter /
Med Dent Vis
*Wife, Husband, Same-Sex Domestic Partner, Son or Daughter. You must provide a marriage certificate or affidavit of Domestic Partnership to cover any Wife, Husband or Same-Sex Domestic Partner. A birth certificate must be provided for each dependent child you are covering showing either your name as a parent or the name of your spouse/same sex domestic partner as a parent.

Section III: BENEFIT ELECTIONS

/
MEDICAL PLAN / Waive / Employee Only / Employee + Spouse/DP / Employee + Child(ren) / Family
Exelis Health Savings Plan (EHSP)
Exelis Health Plan (EHP)
Aetna Global Medical Plan
(required for international long term/permanent assignment employees)
I choose to Waive Medical coverage for 2013
DENTAL PLAN / Waive / Employee Only / Employee + Spouse/DP / Employee + Child(ren) / Family
Exelis National MetLife Dental PPO Plan
Aetna Global Dental Plan
(required for international long term/permanent assignment employees)
I choose to Waive Dental coverage for 2013
VISION PLAN / Waive / Employee Only / Employee + Spouse/DP / Employee + Child(ren) / Family
Exelis National EyeMed Vision Plan
Vision Service Plan (VSP) – Vision Plan
I choose to Waive Vision coverage for 2013
FSA/HSA PLANS / Waive / Contribute
Healthcare Flexible Spending Account (HFSA) (not available with EHSP) / I elect an annual contribution of: $ (min$100/ max $2,500)
Dependent Day Care Flexible Spending Account (DFSA) / I elect an annual contribution of: $ (min$100/max $5,000)
Health Savings Account (HSA) only allowed with EHSP You must also complete the HSA bank account application form on mycignaplans.com Login: ExelisActive2013 Password: Cigna (case sensitive) / I elect an annual contribution of: $ (max $2,850single/$5,650 family)
Health Savings Account Catch-up
only allowed with EHSP / I am at least 55 years old this year and
I elect an annual contribution of: $ (max $1,000)
DISABILITY PLANS / Waive / Enroll
Long Term Disability / I elect to enroll
SUPPLEMENTAL ACCIDENTAL DEATH & DISMEMEBERMENT (AD&D) PLAN / Waive / Enroll
Voluntary Accident Insurance
Must elect in $10,000 increments up to $500,000 maximum / Plan I Employee Only
Principal Sum Elected $ / Plan II Employee + Family
Principal Sum Elected $
OTHER VOLUNTARY BENEFITS / Waive / Contribute
Life Plus Supplemental Life Insurance plan for Employees, Spouses and Children / To enroll in the Life Plus Supplemental Life Insurance plan you must do so at www.ittexelisvoluntarybenefits.com within 30 days of your date of hire for guaranteed issue.
LEGAL PLAN / To enroll in the Legal plan you must do so at www.ittexelisvoluntarybenefits.com within 30 days of your date of hire.
GROUP AUTO/HOME INSURANCE / To enroll in the Group Auto/Home Insurance plan you must do so at www.ittexelisvoluntarybenefits.com.
RETIREMENT BENEFITS / Discuss your 401k benefits with your local Human Resources representative to find out how to enroll, select investment funds and designate a beneficiary directly on the 401k providers website.
EXELIS PROVIDED LIFE INSURANCE / The Company provides 1x/salary in Company Paid Basic Life insurance
Beneficiary Information for EXELIS Paid Life Insurance
Name /
Birth date
/
Relationship
/
Address
/ %Share
EXELIS PROVIDED AD&D INSURANCE / The Company provides 1x/salary in Basic Accidental Death and Dismemberment (AD&D) Insurance
Beneficiary Information for Company Paid Accidental Death & Dismemberment (AD&D) Insurance
Beneficiaries for this plan are the same as listed above under EXELIS PROVIDED LIFE INSURANCE
Name /
Birth date
/

Relationship

/

Address

/ %Share
EXELIS PROVIDED BUSINESS TRAVEL ACCIDENT (BTA) INSURANCE / The Company provides additional life & AD&D coverage to employees while on business travel

Beneficiary Information for Business Travel Accident (BTA) Insurance

Beneficiaries for this plan are the same as listed above under EXELIS PROVIDED LIFE INSURANCE
Name /

Birth date

/

Relationship

/

Address

/ %Share

All deductions are taken on a pre-tax basis from each paycheck except LTD, Voluntary Accident Insurance, LifePlus Supplemental Life, Legal and Group Auto/Home Insurance.

I authorize my employer to deduct from my salary the necessary premiums for the coverage(s) elected above. I verify that the information provided on this form is accurate and complete. Further, I understand that any change in these coverage elections can only be made as of any January 1 unless a qualified status change occurs and I make a new election within 30 days following such change.