Preferred Choice Program Enrollment Form Elections Valid June 1, May 31, 2014

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1 Preferred Choice Program Enrollment Form Elections Valid June 1, May 31, 2014 Complete if enrolling a Employee Name Employee # Work Location Effective Date IRS rules governing taxation require that Atkins include the fair market value of domestic partner benefits in employees incomes, referred to as imputed income. The IRS allows the employee to receive tax free employer insurance subsidies for eligible dependents as defined under IRS guidelines. However, if any part of such a subsidy is used to offset premiums for a tier of coverage that includes a domestic partner and/or a dependent of a domestic partner, those monies are considered additional taxable income to the employee. s for domestic partners are also processed after-tax. Noted below is the imputed income associated with each coverage level and type. You will see this amount listed on your bi-weekly paytubs. Please elect coverage for yourself and eligible dependent(s) Medical Plan (1 of 2): Cigna High Deductible Health Plan (HDHP) s Per Pay Period Your s Per Pay Period Your s Per Pay Period Your Imputed Income(Bi-weekly) Domestic s Per Pay Period Your Imputed Income(Bi-weekly) DP s Per Pay Period + DP Your Imputed Income(Bi-weekly) *Circle Option Option 5 Health Savings Account (HSA) (Only Applies when enrolling in the HDHP) 2013 IRS Individual Maximum ($3,250) 2013 IRS Family Maximum ($6,450) Direct Contribution Per Pay Period Annual Direct Contribution $ $ $ $ *Please review eligibility requirements for the HSA before electing. The Atkins Employer contribution for the June 1, 2013 plan year is $500 for Individual and $1000 for Family. Contribution amount is prorated when enrolling after June 1, HSA election is not required. According to IRS regulations, expenses for a domestic partner are not reimbursable under the employee's HSA. The domestic partner however may be eligible to establish their own HSA separately through HSA Bank or any other HSA provider. For more information contact HSA Bank, at Page 2

2 Medical Plan (2 of 2): Cigna Open Access Plus Plan (OAP) s Per Pay Period Your s Per Pay Period Your s Per Pay Period Your Imputed Income(Bi-weekly) Domestic s Per Pay Period Your Imputed Income(Bi-weekly) DP s Per Pay Period + DP Your Imputed Income(Bi-weekly) *Circle Option Option 5 Page 3

3 Metlife Dental Plan s Per Pay Period Your s Per Pay Period Employee+ Your s Per Pay Period Your Imputed Income(Bi-weekly) + Domestic s Per Pay Period Your Imputed Income(Bi-weekly) + DP s Per Pay Period & DP Your Imputed Income(Bi-weekly) Circle YES if you are declining Medical and/or Dental coverage. Medical Opt-Out/Dental Opt-Out Yes, I have elected not to participate in the Preferred Choice Program, medical plan. Yes, I have elected not to participate in the Preferred Choice Program, dental plan. Initials: Initials: Page 4

4 Eye Med Vision Plan s Per Pay Period Your s Per Pay Period Employee+ Your s Per Pay Period Your Domestic s Per Pay Period Your DP + DP s Per Pay Period Your *Circle Option Option 5 Flexible Spending Accounts Flexible Spending annual contributions will be evenly divided by the number of pay periods remaining in the plan year. Reimbursements will be made for expenses incurred in the same plan year in which payroll deductions take place AND while you actively contribute to the account(s). Decline FSA Initials: *Not Eligible if Enrolled in the HDHP Election requires a minimum contribution of $240 and annual maximums for each account are provided below *Flexible Spending Accounts (Use it or lose, IRC rule applicable) Direct Contribution Per Pay Period(3) $ Annual Direct Contribution(3) $ (1) Items such as deductibles, co-payments, etc., NO PREMIUMS. (2) Child/Elder care of eligible dependents. (3) Amounts you choose to voluntarily contribute Mandatory Disability Plans, Life/AD&D Health Care Account (annual max: $2,500) (1) $ $ Dependent Day Care Account (annual max: $5,000) (2) Mandatory Disability Plans Employee LTD Employee STD Life, AD&D 2 x Salary up to $150K Company Paid Your Page 5

5 Election of the following plans are voluntary deductions and they are made on an after-tax basis. Indicate your selection(s) in the boxes below: Group Legal Plan Hyatt Legal After-tax Employee Family Your *Circle Option Number Chosen 1 2 Employee Supplemental Life/AD&D After-tax Employee Supplemental Life Insurance Medical underwriting approval required when existing coverage is increased by more than one level or the amount is in excess of 3x base salary or $300,000, whichever is less. Benefits reduced at ages 70 & 75. LIFE/AD&D PLAN After-tax Employee Life Options (in addition to basic life coverage) 25K (add l) 100K (add l) 250K (add l) 400K (add l) 50K (add l) 150K (add l) 300K (add l) 450K (add l) Plan Option: Cost:$ 75K (add l) 200K (add l) 350K (add l) 500K (add l) Employee s Age as of June 1 < 25 Rate/ Reduced to 65% Benefit Reduced to 50% Benefit Dependent Life Options Medical underwriting approval is required when existing coverage is increased more than one level. coverage limited to 50% of employees coverage amount. *MEDICAL UNDERWRITING APPROVAL IS MANDATORY FOR LEVELS: $75K, $100K, $125K, $150K. Plan Option Spouse/ Benefit Level $2K $10K $20K $25K $50K Cost $0.18 $0.63 $1.19 $1.45 $2.80 Plan Option Spouse/ Benefit Level $75K $100K $125K $150K Cost $4.16 $5.55 $6.94 $8.33 After-Tax Plan Option(s) Cost: $ Child Life Insurance Plan Option A Child Coverage $10K Cost $1.06 Page 6

6 Long Term Care (UNUM) After-Tax Please refer to the rate sheets included in the LTC Enrollment Kit. Rates are based on individual s age at the time of enrollment, plan option selected, and benefit period duration & amount requests. Benefit effective on the 1st of the month after eligibility & election Duration (5 yrs or 3 yrs): Plan Option #: Plan Option Numbers *Please circle option chosen EE Coverage Level EE+DP Benefit Amount Coverage Level: (increments of $1K) 5 Years $1,000 to $6,000 Benefit Amount:$ 3 Years ,2,3,4,5,6 Premium: $ LTC Benefits are also available for other family members on a non-payroll deduction bases. Please consult your local Human Resources Representative for more information. Cost Summary Please total all pre-tax bi-weekly premium costs and write that figure below. Pre-tax Premiums $ Please total all after-tax bi-weekly premium costs and write that figure below. After-tax Premium(s) $ Premiums $ Page 7

7 In order to enroll any eligible dependent(s), you are required to submit documentation substantiating the relationship. * Relationship Dependent up to age 26 Acceptable Documentation Copy of certificate of registration of domestic partnership, or completion of the Atkins Declaration of ship Copy of birth certificate(s), adoption document(s) or other court documentation verifying legal guardianship Please provide the following information for all dependents enrolled in any of the above benefits. Name of Covered Dependent : Date of Birth Social Security Relationship Dependent Address Information (if applicable): NOTE: This program is under Internal Revenue Code 125, it is subject to its regulations and you cannot change your elections within the plan year unless you experience a change in family status as outlined in the Preferred Choice booklet. Requests, in writing, must be made on a prospective basis in anticipation of the family status change event. For consideration, the written request must be received by Human Resources within 30 days of the event. Third party documentation verifying the status change is required. Benefit changes must be on account of and consistent with your family status change. Supporting documentation will be required. No retroactive request will be processed except requests to add newborns and adopted children. Life Insurance Beneficiary and Benefit Percentage: Beneficiary Name Percentage Date of Birth SSN Relationship Remember - Your enrollment forms must be submitted to complete your elections. I authorize payroll deductions for the necessary amounts as shown above. However, if I fail to complete and return the required enrollment form(s) within thirty (30) days of my eligibility and election of that coverage, my election will be considered invalid for the particular plan(s). Accordingly, I give my authorization for the appropriate adjustments to be made to my election(s) and that any misstatement may result in denial of benefit and/or termination of coverage/membership. I understand that any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a third degree felony. Employee's Signature Date Page 8