EMPLOYEE INFORMATION (Please Print)
Last Name / First Name, Middle Initial / Social Security Number
Address - Street
/City
/State
/ Zip / o Maleo Female
Home Phone / Date of Hire / Date of Birth / oSingle
oMarried / o Divorced
o Domestic Partner
Are you or any dependents covered under Medicare? o Y o N
Name of Medicare Dependent: / If Yes for Medicare for you,
Part A: o Y o N Part B: o Y o N
If Yes for your dependent,
Part A: o Y o N Part B: o Y o N
1. ENROLLMENT EVENT TYPE
o Annual Open Enrollment o New Enrollment
o Newborn/Adoption o Marriage (Date ____/____/____)
o Domestic Partner o Approved Qualifying Event / Effective Date of Event: ______OR
Re-Hire date: ______
2. MEDICAL COVERAGE: Check your plan choice and coverage tier for medical coverage.
PLAN CHOICE / EMPLOYEE ONLY / EMPLOYEE
& SPOUSE / EMPLOYEE & DOMESTIC PARTNER / EMPLOYEE CHILD(REN) / EMPLOYEE
FAMILY
o Kaiser Permanente HMO #192 / o / o / o / o / o
o United Healthcare HMO* / o / o / o / o / o
o United Healthcare PPO/HSA** / o / o / o / o / o
o Opt Out - Decline Coverage <Complete Section “9” for Declining Medical Coverage.>
*HMO Enrollment Requires Primary Care Physician selection (Section 8).
**PPO/HSA enrollment requires separate bank acct paperwork, see HR.HSA contributions must be renewed every year.
3. DENTAL COVERAGE: Check the choice and coverage tier you elect for dental coverage.
PLAN CHOICE / EMPLOYEE ONLY / EMPLOYEE & SPOUSE / EMPLOYEE & DOMESTIC PARTNER / EMPLOYEE CHILD(REN) / EMPLOYEE FAMILY
o UHC Dental PPO / o / o / o / o / o
o UHC Dental HMO / o / o / o / o / o
o Opt Out - Decline Coverage o / Give reason: o Spouse’s Coverage o Individual Coverage o Other:______
4. VISION COVERAGE: Check the choice and coverage tier you elect for vision coverage.
PLAN CHOICE / EMPLOYEE ONLY / EMPLOYEE
& SPOUSE / EMPLOYEE
DOMESTIC PARTNER / EMPLOYEE CHILD(REN) / EMPLOYEE FAMILY
o UHC Vision / o / o / o / o / o
o Opt Out - Decline Coverage
5. BASIC LIFE & AD&D INSURANCE: (subject to eligibility)
(1x Salary to $150,000 Benefit. Coverage provided through UNUM)
p Enroll - Paid for by Saint Mary’s College – Group #143461 001
6. LONG TERM DISABILITY: (subject to eligibility)
(60% of base salary to maximum of $10,000 per month) Coverage provided through UNUM Insurance Company
p Enroll - Paid for by Saint Mary’s College – Group #143461 002
7. VOLUNTARY LIFE INSURANCE: Requires a separate enrollment form – please contact HR.
o No Changes o New Election o Changing Coverage o Opt Out – Decline Coverage Note: Paid for by Employee with post tax dollars
Saint Mary’s College Benefit Enrollment Form Page 2 of 4
8. DEPENDENT PERSONAL INFORMATION: (You do not need to complete Section 8 if you are not enrolling your dependents) Complete section for yourself and your dependent(s) or if you have changed plans or changed current dependent status. Use a second enrollment form for additional dependents. *Affidavit of domestic partnership must be signed. See HR for form.Name (Include Last, First and Middle Initial) / M/F / Date of Birth / Social Security Number / Coverage Election / Other Medical Coverage / Kaiser MRN (if you have one) OR
United Healthcare HMO Group/IPA# and IPA Primary Care Physician # / Current HMO MD?
Employee: / Medical o
Dental o
Vision o / o Y
o N / o Y
o N
Spouse/Domestic Partner / Medical o
Dental o
Vision o / o Y
o N / o Y
o N
Child: / Medical o
Dental o
Vision o / o Y
o N / o Y
o N
Child: / Medical o
Dental o
Vision o / o Y
o N / o Y
o N
Child: / Medical o
Dental o
Vision o / o Y
o N / o Y
o N
9. DECLINING MEDICAL COVERAGE
If you are declining enrollment for yourself or your dependents (including your Spouse/DP) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 31 days after your other coverage ends. This 31-day period is called the special enrollment period. A special enrollee is not a late enrollee. Proof of creditable coverage from other insurance will apply towards the pre-existing limitation. In addition, you may be able to enroll yourself and your dependents, provided that you request enrollment within 31 days after a Qualified Status Change. If you are declining enrollment for any other reason, or if you fail to complete this form, you may be subject to certain policy or plan provisions including but not limited to enrollment permitted only during the annual enrollment period and a 6 month pre-existing condition limitation or exclusion period upon enrollment.
I am declining coverage for: o Myself o My Spouse/DP o My Child(ren) o My Spouse/DP and My Child(ren)
o I (we) have other medical coverage or COBRA:
Name of my (our) other carrier(s) Group Plan # ______
o I (we) do not have other medical coverage.
I have read the above and acknowledge that I have been given the opportunity to enroll myself and (if applicable) my eligible dependents. I also acknowledge receipt of this Notice.
Signature Date
10. PRIOR COVERAGE INFORMATION (Needed only for those electing PPO coverage for first time)
Please fill out the following information to receive proper credit for PREVIOUS COVERAGE if immediately prior to becoming eligible for this plan, you or your dependents were covered under any public or private health care coverage (including MediCal or Individual coverage). According to federal law, your employer or FORMER CARRIER must provide you with a certificate that shows evidence of your prior coverage. We reserve the right to request a copy of this certificate.
Employee:
Carrier Name Coverage Begin Date Coverage End Date Reason for Ending Coverage
Spouse/DP:______
Carrier Name Coverage Begin Date Coverage End Date Reason for Ending Coverage
Child(ren): ______
Carrier Name Coverage Begin Date Coverage End Date Reason for Ending Coverage
List children separately if coverage is not the same for each
Saint Mary’s College Benefit Enrollment Form Page 3 of 411. AUTHORIZATION: To be signed by all employees applying for either United Healthcare or Kaiser Permanente coverage.
Kaiser Foundation Health Plan Arbitration Agreement:
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure, and, claims that cannot be subject to binding arbitration under governing law), any dispute between myself, my heirs, relatives, or other associated parties on the one hand and Health Plan, its health care providers, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in Health Plan, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Evidence of Coverage.
Employee Signature ______Date ______
Required for Kaiser Permanente HMO Plan
Authorization to Release Medical Information and Signature for United Healthcare
I authorize United HealthCare Insurance Company and its affiliates (“UnitedHealthcare and Affiliates”) to obtain, use and disclose my medical, claim or benefit records, including any individually identifiable health information contained in these records. I understand these records may contain information created by other persons or entities (including health care providers) as well as information regarding the use of drug, alcohol, HIV/AIDS, mental health (other than psychotherapy notes), sexually transmitted disease and reproductive health services. I authorize any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical facility, health care clearinghouse, and any of their affiliates, representatives or business associates, who may be in possession of my confidential health information, to disclose my information to UnitedHealthcare and Affiliates. I understand this authorization is voluntary and I may refuse to sign the authorization. My refusal may, however, affect my ability to enroll in the health plan or receive benefits, if permitted by law. I understand I may revoke this authorization at any time by notifying my UnitedHealthcare and Affiliates representative in writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare and Affiliates also request that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain and use may be re-disclosed (with the exception of HIV/AIDS health information) and no longer protected by federal privacy regulations except as prohibited by state law. This authorization, unless revoked earlier, expires 30 months after the date it is signed. I understand that I am completing a joint life and health application and that each response must be complete and accurate. I (we) request the indicated group medical coverage for myself and, if the plan provides, for my dependents. I authorize any required premium contributions to be deducted from earnings. I (we) have not given the agent or any other persons any health information not included on the Request for Coverage. I (we) understand that the HMO/insurance company(ies) is not bound by any statements I (we) have made to any agent or to any other persons, if those statements are not written or printed on this Request for Coverage and any attachments.
Employee Signature ______Date ______
Employee (Print Name)______
Binding Arbitration
I AGREE AND UNDERSTAND THAT ANY AND ALL DISPUTES, INCLUDING CLAIMS RELATING TO THE DELIVERY OF SERVICES UNDER THE PLAN AND CLAIMS OF MEDICAL MALPRACTICE (THAT IS, AS TO WHETHER ANY MEDICAL SERVICES UNDER THE HEALTH PLAN WERE UNNECSSARY OR UNAUTHORIZED OR WERE IMPROPERLY, NEGLIGENTLY OR INCOMPLETELY RENDERED), EXCEPT FOR CLAIMS SUBJECT TO ERISA, BETWEEN MYSELF AND MY DEPENDENTS ENROLLED IN THE PLAN (INCLUDING ANY HEIRS OR ASSIGNS) AND UNITEDHEALTHCARE OF CALIFORNIA. UNITEDHEALTHCARE OR ANY OF ITS PARENTS, SUBSIDIARIES OR AFFILIATES, SHALL BE DETERMINED BY SUBMISSION TO BINDING ABRITRTION. ANY SUCH DISPUTE WILL NOT BE RESOLVED BY A LAWSUIT OR RESORT TO COURT PROCESS, EXCEPT AS THE FEDERAL ARBITRATION ACT PROVIDES FOR JUDICAL REVIEW OF ARBITRATION PROCEEDINGS. ALL PARTIES TO THIS AGREEMENT ARE GIVING UP THEIR CONSTITUTIONAL RIGHTS TO HAVE ANY SUCH DISPUTE DECIDED IN A COURT OF LAW BEFORE A JURY AND INSTEAD ARE ACCEPTING THE USE OF BINDING ARBITRATION.
Employee Signature ______Date ______
Employee (Print Name)______
Saint Mary’s College Benefit Enrollment Form Page 4 of 4
12. AUTHORIZATION
UNUM Insurance Company Authorization
· I hereby apply for the group benefit(s) that I have chosen above.· I understand that I must meet eligibility requirements for all coverage’s that I have chosen above.
· I understand that my dependent(s) cannot be enrolled for a coverage unless I am enrolled for that coverage.
· I agree that my employer may deduct premiums from my pay if they are required for the above coverage I have chosen.
· Any person who with intent to defraud or knowing that he/she is facilitating a fraud against the insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Applicable to all carriers
I wish to make the choices indicated on this form and authorize Saint Mary’s College to make any necessary pre-tax or after-tax deductions, current or future. I understand that pre-tax contributions will slightly impact my social security contributions. I certify that the information on this form is complete and accurate. If for any reason I fail to complete a new enrollment form each plan year, the elections shown on this form for my medical, dental and vision will remain unchanged, although the cost may change. In order to continue in the HSA a new election form is required each plan year. If changes occur during the year that affect this information, I will notify Human Resources within 30 days of the change. My payroll deductions may change based on my tenure with Saint Mary’s College and age (Basic Life/Voluntary Life only).I understand that a copy of this form will be made available at my request and that it will be as valid as the original. I declare that the information I have completed on this enrollment form is complete and true. I understand an agent or broker cannot guarantee coverage, revise rates, benefits, or provisions without written approval from the carriers listed on this form.
Employee Signature Date
13. BASIC LIFE BENEFICIARY DESIGNATION: (Unless otherwise specified, payment will be made to the primary beneficiary who survives the insured; if none, by all contingent beneficiaries who survive. If more than 1 beneficiary is named, enter a % for each. If no percentage is shown, equal shares are assumed. The right to change the beneficiary is reserved unless otherwise noted).
If you have designated a minor child(ren) as your beneficiary, you must complete the Uniform Transfers to Minors Act form. If you are not naming an individual or individuals as a beneficiary, check one of the following.
o Estate of Insured o Revocable or Irrevocable Trust (Enter name of Trustee, name of Trust/complete date of Trust.)
o Trustee Under Insured’s Will (If choosing this option DO NOT enter additional names in the Primary Beneficiary field.)
Primary 1 (Last, First, Initial) / Relationship / Date of Birth
Address of Primary Beneficiary (Street, City, State, Zip Code / Percentage:
Primary 2 (Last, First, Initial) / Relationship / Date of Birth
Address of Primary Beneficiary (Street, City, State, Zip Code / Percentage:
Secondary Beneficiary – Second to receive payment (optional)
Contingent 1 (Last, First, Initial) / Relationship / Date of Birth
Address of Primary Beneficiary (Street, City, State, Zip Code / Percentage:
Human Resource Use Only
Coverage Effective Date: / Sent to Carriers Date: / BNDS Form o