Attached Benefit Enrollment Forms must be returned to the Business Office within 30 days after your first day of work

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1 Attachd Bnfit Enrollmnt Forms must b rturnd to th Businss Offic within 30 days aftr your first day of work Insuranc Enrollmnt Form Elct or Waiv Halth Covrag o B sur to indicat which halth plan you ar lcting Elct or Waiv Dntal Covrag Elct or Waiv Vision Covrag Businss Offic 222 Mapl Avnu, Wauksha WI Fax: Educator s Crdit Union If you ar nrolling in th High Dductibl Halth Plan you will nd to stablish your Halth Savings Account with Educator s Crdit Union prior to your ffctiv dat of covrag. Flxibl Spnding Account Enrollmnt Form: Elct or Waiv participation Indicat contribution for Dpndnt Car (maximum $5,000 annually pr family) Indicat contribution for Mdical Rimbursmnt (maximum $2,500 annually) Lincoln Financial Group Complt nrollmnt form Long Trm Disability is automatic nrollmnt Short Trm Disability is voluntary and th prmium amounts ar indicatd on th form Must lct or waivr of covrag Lincoln Financial Group You must rturn th bnficiary dsignation form indicating a bnficiary for th mployr sponsord lif covrag Disclaimr: If w do not rciv your nrollmnt forms within 30 days of your dat of ligibility (your first schduld workday) you will forfit your initial ligibility priod to nroll in th bnfits providd by th District, with th xcption of any 100% mployr sponsord bnfits of which you ar ligibl. You will b ligibl to nroll during th rspctiv opn nrollmnt priod, or if you hav a qualifying chang of status. If you hav qustions or nd assistanc in complting th forms plas contact th Businss Offic. Mlissa Bck Employ Bnfits Coordinator

2 Pag 1 of 3 INSURANCE: NEW HIRE ENROLLMENT / WAIVER 222 Mapl Avnu Wauksha, WI Ph Fax You must rturn your nrollmnt lctions to th Businss Offic within 30 days of your dat of ligibility or you will forfit your initial ligibility priod to nroll in th bnfits providd by th District, with th xcption of any 100% mployr sponsord bnfits of which you ligibl. Effctiv Dat: This will b th dat your bnfits with th School District of Wauksha will bcom ffctiv if you chos to nroll in th halth, dntal or vision options. Plas print th following information: from th documnt or th summary of an Dat of Birth Gndr Hom Phon Numbr M F [Typ Addrss from th documnt or th summary Apt. # of an intrsting City point. You can position th Stat txt box anywhr Zip in th documnt. Us th Drawing Tools tab to chang th formatting of th pull quot txt box.] [Typ from th documnt or th summary of an intrsting point. You can position th txt box anywhr in thdocumnt. Us th Drawing Tools tab to chang th formatting of th pull quot txt box.] Occupation: Administrator Prinicipal/Mid-managr Non-unit Tachr Custodial /Maint. Twlv-month clrical Tn-month clrical Halth room clrical Educational Assistant Othr Dat of Hir Annual Salary Numbr of Hours Workd Pr Wk ENROLL: (Circl all that apply) Mdical: Traditional Plan HDHP* WBP* Dntal Vision *HDHP= High Dductibl Halth Plan, *WBP = Wag Basd Prmium Plan du to ACA

3 Dpndnt Information List all Enrolling Dpndnts (Attach additional sht if ncssary). Plas Print. (Dpndnts will b nrolld in th halth plan slctd on Pag 1) from th documnt or th summary of an Dat of Birth Gndr Rlationship Full-tim Studnt Enroll: (Circl all that apply) Mdical Dntal Vision from th documnt or th summary of an Dat of Birth Gndr Rlationship Full-tim Studnt Enroll: (Circl all that apply) Mdical Dntal Vision from th documnt or th summary of an Dat of Birth Gndr Rlationship Full-tim Studnt Enroll: (Circl all that apply) Mdical Dntal Vision from th documnt or th summary of an Dat of Birth Gndr Rlationship Full-tim Studnt Enroll: (Circl all that apply) Mdical Dntal Vision from th documnt or th summary of an Dat of Birth Gndr Rlationship Full-tim Studnt Enroll: (Circl all that apply) Mdical Dntal Vision from th documnt or th summary of an Dat of Birth Gndr Rlationship Full-tim Studnt Enroll: (Circl all that apply) Mdical Dntal Vision

4 Halth Savings Account - Payroll Dduction Contribution Form Us this form to start, stop or chang contributions to your HSA through payroll dductions. Employ's Information Submit Form To - or Fax- (262) Employ ID Daytim Phon Dat of Birth Mdical Plan Covrag Singl Employ + Dpndnts Employ HSA Contributions I authoriz School District of Wauksha to dduct from my paychck th following pr-tax amount for contributions to my Halth Savings Account with Educators Crdit Union. GENERAL RULES An mploy may mak quartrly lction changs to thir HSA dductions on 1/15, 4/15, 7/15 and 10/15. TOTALANNUALALLOWED 2015 Singl Maximum Allowd: $3, * Employr contributs $1,300 annually 2015 Family Maximum Allowd: $6, * Employr contributs $2,600 annually *You ar 55 or oldr and ar allowd to add an additional $1, as a catch-up contribution to your HSA. Important: If you hav prviously contributd to your HSA via payroll dduction or dirctly to your account during th currnt plan yar, you nd to track your annual contributions to nsur you do not xcd th annual maximum allowd. Maximum EMPLOYEE Contribution (for th 2015 calndar yar only) $2,700 Singl ($3,350 - $650 mployr = $2,700) $5,350 Family ($6,650 - $1,300 mployr = $5,350) SELECT DEDUCTION AMOUNT Pr Paychck Dduction: $ How much do you want to b dductd pr paychck? HSA dductions will continu unlss you submit a quartrly chang rqust to th payroll offic indicating diffrnt. Employ Signatur Dat of rqust: Plas scan and mail compltd form to o r fax to (262)

5 Flxibl Bnfit Plan Enrollmnt Form Plas Print Employ Soc. Sc. # - - Employr Wauksha School District Branch/Location Plan Yar: / / to / / Numbr of payroll dductions: Ia. Group Insuranc Prmiums: Dat of first dduction: Group insuranc prmiums will b dductd pr-tax automatically. Contact th bnfit rprsntativ at your mployr if you hav qustions rgarding your group insuranc prmiums. Ib. Indpndnt Prmium Fatur: I undrstand this is for indpndnt halth insuranc prmiums only. Do not complt this sction for your group halth insuranc prmium through your mployr. I lct $ x =$ for indpndnt prmiums for th abov plan yar. (pr payroll dduction) (# of payroll dductions) (total lction) II. Dpndnt Car Rimbursmnt Account: I lct $ x =$ for dpndnt car xpnss for th abov plan yar. (pr payroll dduction) (# of payroll dductions) (total lction) III. Mdical Rimbursmnt Account: I lct $ x =$ for rimbursabl mdical xpnss for th abov plan yar. (pr payroll dduction) (# of payroll dductions) (total lction) IV. Othr Contribution: V. Waivr I do not want to participat in th Flxibl Bnfit Plan (aras Ib, II, & III abov). My Employr has offrd m th opportunity to nroll and I am dclining to participat for th abov plan yar. I undrstand that my mployr will dduct my lction in qual amounts from my paychck throughout th plan yar. If at th nd of th plan yar th total dclard rduction in my compnsation xcds th substantiatd xpnss, I undrstand that th rmaindr will bcom th proprty of my mployr. I also undrstand that I will hav an opportunity to mak a nw lction, if I so dsir, prior to th bginning of ach subsqunt plan yar, in accordanc with th procdurs dscribd in th Plan Documnt. By affixing my signatur blow, I crtify that I hav xamind this Agrmnt and undrstand and agr to comply with th trms of th plan and applicabl cod sctions of th Flxibl Bnfit Plan. All amounts listd will b incurrd (maning having a dat of srvic) within th Flxibl Bnfit Plan Yar. I also undrstand that Divrsifid Bnfit Srvics, Inc. is not ngagd in giving tax or lgal advic and that I hav consultd with my tax accountant on th appropriatnss of th plan for m. I also undrstand that my monthly Social Scurity rtirmnt bnfit, if I rciv on, may b rducd slightly by contributing pr-tax dollars to a Flxibl Bnfit Plan. Also, by providing an lctronic mail addrss (-mail), consnt is givn to rciv unncryptd information rgarding my FSA rimbursmnt account, including claims and prsonal halth information, in lctronic form at th -mail addrss providd. Employ City, Stat, Zip: Employ #: Daytim Tlphon: ( ) -mail: Employ Signatur: Dat: P.O. Box 260 Hartland, Wisconsin (262) (800) Fax (262)

6 ENROLLMENT FOROR GROUP INSURANCE Th Lincoln National Lif Insuranc Company P.O. Box 2616, Omaha, NE Phon: (800) Fax: (877) Plas Us Ink or Typ GROUP ID: WAUKSD GROUP POLICY #: , Billing Division or Location: , A. Employ Information (Complt for ALL Enrollmnts) Employr /Company (Plas Print) School District of Wauksha County Employr ZIP Stat WI Employ Middl Initial Social Scurity Numbr Dat of Birth Spous Middl Initial Social Scurity Numbr Dat of Birth Strt Addrss City Stat Zip Gndr: Mal Fmal Marital Status: Marrid Singl Hom Phon ( ) Compltd By Employr Avrag Hours Workd Pr Wk: Occupation: Work Phon ( ) Earnings: Hourly Monthly Wkly Yarly $ Dat of Full-Tim Employmnt: Rhir Dat: B. Product Slction (Complt for ALL Enrollmnts) Basic Covrag NOTE: Plas mark th box or boxs for ach covrag you ar applying for. All covrag amounts ar subjct to th limitations and xclusions as statd in th policy. Class Effctiv Dat Typ of Covrag Amount of Covrag Total Prmium Basic Group Lif/AD&D Ys No* $ Employr Paid Short Trm Disability Ys No* $ Employ Paid Long Trm Disability Ys No* $ Employr Paid *By slcting No, application for covrag at a latr dat may rquir furthr mdical information and/or a physical xam, which will b at my own xpns. --Actual dductions may vary slightly from abov illustrations du to rounding-- Short-Disability Covrag Rats Th cost of th short-trm disability insuranc is calculatd basd on th actual bnfit providd to th mploy if that mploy bcam disabld. Bnfit amounts ar availabl in $50 incrmnts up to $500 pr wk. Th monthly prmium cost is $.60 pr $10 in wkly bnfit amount. Wkly Bnfit Amount X $.60 = Monthly Prmium $10 Annual Minimum Salary Wkly Bnfit Amount Monthly Prmium $11,460 $150 $9.00 $17,450 $200 $12.00 $20,000 $250 $15.00 $22,800 $300 $18.00 $26,500 $350 $21.00 $32,800 $400 $24.00 $35,500 $450 $27.00 $39,300 $500 $30.00 Lincoln Financial Group is th markting nam for Lincoln National Corporation and its affiliats. GLAD 4 01/12

7 C. Bnficiary Information (Complt ONLY for Lif/AD&D or Accidnt with AD&D) Primary Bnficiary's First Rlationship of Bnficiary Social Scurity Numbr Plas complt sparat Bnficiary Dsignation Form includd in your packt. Strt Addrss City Stat Zip Contingnt Bnficiary's First Rlationship of Bnficiary Social Scurity Numbr Strt Addrss City Stat Zip Not: A Contingnt Bnficiary will rciv bnfits only if th Primary Bnficiary dos not surviv you. If you wish to dsignat mor than on Primary or Contingnt Bnficiary, plas attach a sparat sht of papr. E. Rqust for Covrags This covrag has bn offrd to m and aftr carful considration of th bnfits, I hav dcidd to: D REQUEST COVERAGE for which I am or may bcom ligibl undr th group policis issud by Th Lincoln National Lif Insuranc Company. I hrby nroll for group insuranc, for which I am ligibl or may bcom ligibl. If contributions ar rquird, I authoriz my mployr to dduct prmiums from my salary. D NOT ENROLL myslf in th Program. I undrstand that if I nroll for covrag at a latr dat, and if a physical xamination or furthr mdical information is rquird, it will b at my own xpns. D NOT ENROLL my dpndnts in th Program. I undrstand that if I nroll for covrag for my dpndnts at a latr dat, and if a physical xamination or furthr mdical information is rquird, it will b at my own xpns. NOTE: A PERSON MAY BE COMTTING INSURANCE FRAUD, IF HE OR SHE SUBTS AN APPLICATION OR CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT WITH INTENT TO DEFRAUD (OR KNOWING THAT HE OR SHE IS HELPING TO DEFRAUD) AN INSURANCE COMPANY. Th insuranc rqustd on this nrollmnt form will not b ffctiv until approvd by th Group Insuranc Srvic Offic of Th Lincoln National Lif Insuranc Company, or its insuranc partnrs, and th initial prmium is paid to Th Lincoln National Lif Insuranc Company. A dlayd ffctiv dat will apply if th mploy is not Activly at Work or an Activ Mmbr, or a dpndnt is in a priod of limitd activity on th dat insuranc would othrwis tak ffct. I undrstand that th vision car insuranc bnfit plan I hav slctd provids rimbursmnt for crtain vision costs which ar mor fully dscribd in th currnt Crtificat of Covrag. I undrstand thr may b instancs whr tratmnt dcisions mad by my providr or m for vision car xpnss which I hav incurrd may not b covrd by my vision car insuranc bnfit plan. Employ Full Employ Signatur: Dat: GLAD 4 01/12

8 Th Lincoln National Lif Insuranc Company, PO Box 2649, Omaha, NE toll fr (800) Fax (800) BENEFICIARY DESIGNATION FORM Policyholdr/Employr Policy Numbr(s) Employ Employ Social Scurity or Crtificat Numbr Employ Addrss (Strt, City, Stat) Employ Tlphon Numbr WHO ARE YOUR BENEFICIARIES? It is vry important to clarly indicat your primary bnficiary(is) and contingnt bnficiary(is). Procds ar paid to contingnt bnficiary(is) only if thr is no surviving primary bnficiary(is). If multipl primary bnficiaris or contingnt bnficiaris ar namd and no prcntag distribution is notd, thn any procds payabl to such bnficiaris will b split qually. If mor spac is ndd to list your bnficiaris plas attach a sht to this form. Th bnficiary(is) namd on this form will b valid for all basic, optional, and/ or voluntary group trm lif and AD&D covrags unlss othrwis indicatd by you. Th bnficiary dsignation may not go into ffct until this form is signd and datd by you. Pag 2 of this form includs xampls of how to complt this form. Primary Bnficiary(is) Social Scurity Primary Bnficiary s and Addrss Numbr Rlationship to You Dat of Birth Prcntag: Must qual 100% Contingnt Bnficiary(is): Contingnt bnficiaris will only rciv bnfit if thr ar no surviving primary bnficiaris. Social Scurity Rlationship Dat of Prcntag: Contingnt Bnficiary s and Addrss Numbr to You Birth Must qual 100% Community Proprty Stat Consnt for rsidnts of Arizona, California, Idaho, Louisiana, Nvada, Nw Mxico, Txas, Washington, or Wisconsin. If you ar marrid, liv in a community proprty stat, and nam somon othr than your spous as bnficiary, you may hav your spous sign blow to waiv his or hr rights to any community proprty intrst in th bnfit. As th Insurd s spous, I do hrby consnt to th bnficiary dsignation(s) indicatd on this form and waiv any rights that I may hav to th procds of such insuranc undr applicabl community proprty laws. Signatur of Spous Dat Signatur of Employ Dat Lincoln Financial Group is th markting nam for Lincoln National Corporation and its affiliats. Pag 1 of 2 GLC /11

9 COMPLETING YOUR BENEFICIARY DESIGNATION FORM 1. At th top of th form, fill in th information rgarding your mployr and yourslf. 2. Nxt complt th information rgarding who will b your primary and contingnt bnficiaris. A primary bnficiary will b th prson/popl that you want to rciv th lif insuranc bnfit. Th contingnt bnficiary or bnficiaris will only rciv th lif insuranc bnfit if th primary bnficiary(is) is no longr living. Indicat th prcntag of th bnfit amount that th bnficiary will rciv. Do not us dollar amounts. Prcntags must add up to 100%. 3. If you liv in a community proprty stat, ar marrid and naming somon othr than your spous as th primary bnficiary, you should hav your spous sign this form to avoid any dlays at claim tim. 4. Sign and dat th form. Blow is an xampl of how to complt th bnficiary dsignations: Primary Bnficiary(is) Social Scurity Primary Bnficiary s and Addrss Numbr Jill Do Rlationship to You Dat of Birth Prcntag: Must qual 100% 123 Main St, Anytown, NE xxx-xx-xxxx Wif xx/xx/xx 100% Contingnt Bnficiary(is): Contingnt bnficiaris will only rciv bnfit if thr ar no surviving primary bnficiaris. Contingnt Bnficiary s and Addrss Social Scurity Numbr Rlationship to You Dat of Birth Prcntag: Must qual 100% John Do Sr 456 Main Ln, Anytown, NE XXX-XX-XXXX Fathr XX/XX/XX 50% Mary Do 789 Main Rd, Anytown, NE XXX-XX-XXXX Sistr XX/XX/XX 25% Jack Do Irrvocabl Trust, Jill Do TTEE UTA 1/ Main St, Anytown, NE XXX-XX-XXXX Trust 25% Frquntly Askd Qustions Should I nam a minor child as a bnficiary? You may nam a minor child as a bnficiary, howvr plas b awar that w cannot mak paymnt of a claim dirctly to a minor. If a claim is incurrd w would nd to mak paymnt via UTMA or to th guardian of th minor s financial stat. Or, if guardianship is not obtaind and if UTMA dos not apply, th bnfit will b placd On Hold - Ag of Majority and payabl onc th minor rachs th ag of majority. How would I nam a Charitabl Organization as a bnficiary? A charitabl organization that is not your mployr may b namd as a bnficiary. You will nd to indicat th nam of th charitabl organization, a contact for th organization, thir tax idntification numbr, and th prcntag of th bnfit that would b payabl to thm. How do I nam my Estat as th bnficiary? You may nam your stat as a bnficiary. To nam your stat as th bnficiary indicat My Estat as th bnficiary. If you know who will b th xcutor or administrator of your stat you should also includ that prson s nam. For xampl: My Estat, John Do Excutor. How do I nam a Trust as th bnficiary? You may dsignat a trust as a bnficiary. To nam a trust as a bnficiary, indicat Trust (show and addrss) undr Trust Agrmnt Datd (show dat). If th trust has a tax idntification numbr that will nd to b supplid in plac of th social scurity numbr. For xampl: Jack Do Irrvocabl Trust, Jill Do TTEE UTA 1/1/04. Pag 2 of 2 GLC /11

Remember you can apply online. It s quick and easy. Go to www.gov.uk/advancedlearningloans. Title. Forename(s) Surname. Sex. Male Date of birth D

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