Benefits Enrollment/Change Form Workforce Management Organization

Transcription

1 Benefits Enrollment/Change Form Workforce Management Organization Instructions New Hire Enrollment Check New Hire Enrollment Below Complete Sections I, II and IV Completely Attach Proof of Other Medical Coverage if Waiving Tulane Coverage If Enrolling a Domestic Partner, see Section V ust be received by WFMO within 31 Days from Date of Hire Status Change (Mid-Year Check Status Change Request Below Election Change Request) Complete Sections I, III and IV Completely Attach Proof of Other Medical Coverage if Waiving Tulane Coverage If Enrolling a Domestic Partner, see Section V ust be received by WFMO within 31 Days from Date of the Status Change Event Beneficiary Change Check Beneficiary Change Only Below Complete Sections I and IV Completely Deliver to WFMO New Hire Enrollment Status Change Request Beneficiary Change Only Date: Section I Employee Information Employee Information Participant Name (Last, First, Middle) Social Security Number Date of / Date of Hire Marital Status Gender Single arried ale emale Department or Work Location Work Phone Number Home Phone Number Home Address City Home Address State, Zip Work Address

2 Dependent Information Name (Last, First, MI) Relationship Social Security Number Date of Gender Tulane University Employee Spouse or Domestic Partner Primary Beneficiary Information (For Life and AD&D Insurance and University Death Benefit) Name (Last, First, MI) Relationship Address Phone Date of % of Total Total = 100% Contingent Beneficiary Information (For Life and AD&D Insurance and University Death Benefit) Name (Last, First, MI) Relationship Address Phone Date of % of Total Total = 100%

3 Section II Enrollment Election or Change Request Elections Medical Plan High Option Plan id Option Plan Low Option Plan Dental Plan Vision Plan Healthcare Flexible Spending Account Dependent Care Flexible Spending Account Employee Accidental Death & Dismemberment Insurance Family Accidental Death & Dismemberment Insurance $ Per Pay Period Waive Participation $ Per Pay Period Waive Participation $ (You May Elect Up to $500,000 in $10,000 Increments) Waive Coverage Spouse/Domestic Partner Only Child(ren) Only amily Waive Coverage (Note: For Life Insurance (Supplemental, Spouse, and Dependent), you will be contacted by Standard Insurance with instructions on how to enroll. Section III Change Request Event/Documentation Status Change Event Additional Description (If Required) and Document(s) Provided, Adoption, Placement for Adoption arriage Divorce or Legal Separation Loss or Gain of Other Coverage Spouse Newly Eligible for Other Coverage Annual Enrollment Other

4 Section IV Employee Attestation and Acknowledgement I understand and approve the enrollment as indicated herein. I hereby authorize the Tulane University to deduct from my earnings the amount of my premiums or other contributions (if any) for the benefit options noted selected herein. I further acknowledge that I have received (by separate cover) the employee deduction costs of all benefit plans that I am eligible. I understand that I will not pay Federal Income Tax or FICA tax on my Medical, Dental, Vision, (if elected) and Flexible Spending Account contributions. However, my gross salary before these deductions will be used to figure salary increases or pay-related fringe benefits. Under IRS rules, I may not change my benefit elections during the calendar year unless I experience a qualified change in status. Each year, during the annual enrollment period, I will have the option to change certain coverage whether or not I have had a qualified change in status event during the calendar year (some benefits may have certain enrollment restrictions). In the future, any application to add or increase coverage on me or any of my dependents may require proof of insurability for any person proposed for coverage. Any application must be submitted in accordance with University and/or insurance company guidelines. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires us to inform you of your rights to Special Enrollment under any of the Medical insurance plans offered by Tulane University when you or your eligible dependents (spouse/children) decline coverage during the initial enrollment period. If you are declining enrollment for yourself, or your dependents (spouse/children) because of coverage under another plan, you may in the future be able to enroll yourself or your dependents in one of the Tulane University medical plans, provided you request enrollment within thirty (30) days after your other coverage ends. In order to qualify for this special enrollment period, you must certify other coverage was the reason for declining enrollment and provide the source of that other coverage. I certify that any dependents I am enrolling meet the eligibility requirements described in the benefit enrollment materials. By my signature on this enrollment form, I certify that I understand and agree that to claim coverage for an ineligible dependent is serious misconduct, and in the event of such conduct, I agree to reimburse Tulane University for any cost incurred, and may be subject to disciplinary action. If there is any change in the status of any of the individuals listed on this form, I will be responsible for notifying the University s Workforce Management Organization within 30 days of such change. If you are declining Medical insurance enrollment for yourself or your dependents (including your spouse) because of other insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends. You are required to maintain Medical coverage and provide documentation thereof if you are waiving Medical coverage with Tulane University. In addition, if you have a new dependent as a result of marriage, birth, or adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth or adoption. This form supersedes all forms and submissions I have previously made for Tulane University coverage and Life, AD&D and University Death Benefit Beneficiary(ies) designations. I hereby declare that the above statements are true to the best of my knowledge and belief, and I understand that they are subject to penalty for perjury. Employee Signature Date

5 Section V Domestic Partner Affidavit If you are enrolling a same-sex domestic partner, please complete the attached Affidavit of Domestic Partnership and include with your enrollment form. Submitting Your Enrollment, Status or Beneficiary Change You may mail, hand deliver or secure fax your documentation to: Tulane University Attention: Benefits Team Workforce Management Organization 200 Broadway Street, Suite 120 New Orleans, LA Phone: (504) Fax: (504) Workforce Management Use Only Data Entry Completed By: Accero UHC etlife EyeMed Date Completed: Sent to BCI: