Benefits Enrollment/Change/Decline Form

IMPORTANT INFORMATION READ FIRST

1. BENEFITS MATERIALS - Review the Benefits Choices Guide online so you can make educated benefit elections: www.manateeyourchoice.com 2. WHEN TO USE THIS FORM - Use this form to make your initial benefits election during your 30 day new hire period, to make changes to your benefits during open enrollment period or to make changes to your benefits within 30 days of a qualifying event. 3. CONFIRMATION of BENEFITS ENROLLMENT - This form must be submitted along with proof of eligibility; Marriage Certificates, Birth Certificates, Court Orders and your signed payroll confirmation and Life insurance and LTD Acknowledgement forms after electronically making your benefits election online.

SECTION 1: ENROLLMENT TYPE - CHECK ONE

Benefits effective:

* You have 30 days after a qualifying event to complete and return this form with the proper supporting documentation attached.

OPEN ENROLLMENT -

Benefits effective:

TYPE OF EVENT

EMPLOYEE INFORMATION

EMPLOYEE ID NUMBER Agency E-mail Address

Married Yes No

Date of Birth (mm/dd/yyyy) Hire Date (mm/dd/yyyy)

(First) (Middle Initial) Home Telephone

City, State, Zip

SECTION 2: COVERAGE LEVELS FOR EACH BENEFIT

Employee Only

Employee + Family Employee + 1

Decline Health Coverage Employee + 2 or more (Healthbucks not awarded)

Decline Dental Coverage

SECTION 3: EMPLOYEE AND DEPENDENT COVERAGE INFORMATION

Check Coverage SSN (All that apply)

Medical Dental Additional Life Additional LTD

Medical Dental Voluntary Life

Yes No Tobacco Use Yes No

"Child"

Medical Dental Voluntary Life

Natural Child

Medical Dental Voluntary Life

Medical Dental Voluntary Life

Other Insurance

** If electing benefit coverage for child dependent(s), each meets the eligibility guidelines in the Plan Document. Eligibility for Child Life is restricted to unmarried children under the age of 20 (through 24 if full-time student)

Yes No

"Child" Natural Child

Other Insurance Yes No

Life Insurance

Volume if Applicable

None

None

None

None

None

Tobacco Use Yes No Other Insurance

"Spouse"

Other Insurance

Name: Last, First, MI Date of Birth Gender mm/dd/yyyy M/F

Other Insurance

Natural Child

Yes No Tobacco Use Yes No

Tobacco Use Yes No

Tobacco Use Yes No

Yes No

NEWLY HIRED / NEWLY ELIGIBLE - Hire Date:

Effective: 1/1/

Qualifying Event or Admin Change: Date of Event:

MEDICAL DENTAL Employee Only

"Child"

Name (Last)

Address

Self

Manatee County Government Employee Health Benefits * 941-748-4501 x6403 * www.ManateeYourChoice.com

SECTION 4: OTHER INSURANCE INFORMATION

If you answered yes to other insurance, please provide the following: Name of Insurance

Policy Number

Names of Insured (including self if applicable)

Term date of coverage

SECTION 5: FLEXIBLE SPENDING - You may elect one or both Options

HEALTH CARE FLEXIBLE SPENDING ACCOUNT - Covers eligible health care expenses for you and your federal tax dependents. If enrolling during the plan year (Jan - Dec), your annual election will be divided by the number of remaining pay periods in the plan year.*

I elect to enroll for an annual amount of $

I waive enrollment

DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT - Covers eligible dependent care expenses for your federal tax dependents. To be eligible, expenses must be necessary to enable you or your spouse to be gainfully employed or in search of gainful employment or to attend school on a full-time basis and must be for the care of a child under 13 years of age or a disabled dependent adult.

I elect to enroll for an annual amount of $

I waive enrollment

SECTION 6: Beneficiary Designation

You must select your beneficiary - the person (or more than one person) or legal entity (or more than one entity) who receives a benefit payment if you die while covered by the plans. You may also name a contingent beneficiary - who would receive your benefit if your primary beneficiary dies first. Please make sure your beneficiary designation is clear so that there will be no question as to your meaning. If you name more than one primary or contingent beneficiary, show the percentage of your benefit to be paid to each beneficiary. Please provide all of the information requested below. All employees are automatically covered under our Core Long Term Disability Plan (50% of Base Salary up to $3000.00/month and Core Life Insurance including AD&D. (One(1) times base annual salary rounded up to the next $1000.00. These premiums are paid 100% by the employer. Please refer to the Benefits Choice Guide online for more information, www.manateeyourchoice.com

Core Life

& AD&D

Voluntary Additional

Life

SECTION 7: Employee Confirmation

I Hereby certify that I have been given an opportunity to participate in the Manatee County Government Group Medical Plan offered by my Employer. I authorize my employer to deduct from my pay for any benefits I have elected. I know that I cannot change my benefits unless there is a Family Status Change. I realize that the Plan Sponsor may change premiums and thus change my payroll deduction during the Plan year. I agree to participate in the Pre-Tax Payroll Deduction Programs except if declined.

I understand and agree to abide by the eligibility, enrollment and election procedures of the ManateeYourChoice Plan. I further understand that I am responsible for notifying EHB within 30 days of any changes in my dependents eligibility and coverage and that I am responsible for any claims paid on behalf of my dependents when they were not eligible.

Signed Date

I elect Post-Tax

Full Name Address Social Security # Relationship Date of Birth Percentage Type

Full Name Address Social Security # Relationship Date of Birth Percentage Type

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