BENEFITS ELECTION FORM

Transcription

1 2012 SOIDent alandvi s i onpl anopt i ons Benef i t sef f ec t i vemar c h1,2012 ForPa r t i c i pa nt sofs el ec tcompa ni es

2 Table of Contents Welcome Page 2 Introduction Page 2 Who is Eligible? Page 2 When Can I Join the Plan? Page 3 What is a Preferred Provider Organization (PPO)? Page 3 Qualifying Events/Status Changes Page 3 How Do I Locate Participating Providers? Page 4 Carrier Contact Information Page 4 Frequently Asked Questions Page 5 Supplemental Plan Designs o Guardian Dental Plan Page 8 o EyeMed Vision Plan Page 8 BENEFITS ELECTION FORM Page 9 OPEN ENROLLMENT TERMINATION FORM Page 10 Only for use during Open Enrollment (1/15/2012 2/14/2012) BENEFITS CHANGE FORM Page 11 Only for use outside of Open Enrollment (2/15/2012 2/28/2013) DOMESTIC PARTNERSHIP DECLARATION FORM Page 13 DOMESTIC PARTNERSHIP TERMINATION FORM Page 15 -Page 1-

3 Welcome This enrollment packet contains the information you will need to enroll in the SOI Dental and Vision Plans. Please review this information carefully and select the coverage options that are right for you. Please see your worksite supervisor for information regarding the cost of available plans. Introduction Your company wishes to provide you with a safe work environment and the best employee benefits possible. In order to help protect you and your family s financial security we are pleased to offer you this dental and vision benefit offering. Please read through the following information and the summary plan descriptions carefully before enrolling in the SOI Dental and Vision Plans. SOI assumes that all employees will familiarize themselves with the provisions of the plans. Be advised that the information contained in this document is only an outline of benefits available. More detailed information can be found in the applicable plan document. In case there is a discrepancy between this document and the plan document, the plan document always governs coverage. While allowing flexibility to meet the needs of a wide range of employees, the SOI Dental and Vision Plans provides cost containment by encouraging network use. Who is Eligible? You must meet all of the following criteria to be eligible to participate in the SOI Dental or Vision Plan: You must be actively at work (and being paid by SOI) on a full-time basis. A full-time employee is one who works an average of 30 hours per week, 50 weeks per year. You must be a permanent employee. Temporary employees are not eligible. You must be part of an eligible class of employees. You must work for a client who has chosen to offer the SOI Dental and/or Vision Plans. Eligible employees may also elect to cover their eligible dependents. A dependent is defined by the plan as: A lawful spouse as defined by applicable state law (unless legally separated). Partners who are part of a domestic partnership, civil union, same-sex marriage, or other formal relationship similar to marriage recognized by the laws of the employee s domicile state OR partners who can meet all of the domestic partnership criteria set forth in SOI s Domestic Partnership Declaration form (see the forms section of the booklet for further details). Please note that domestic partnership coverage is offered to both same-sex and opposite-sex couples who meet the domestic partnership criteria. Your natural children, stepchildren, adopted children, children who, are either adopted by you or placed in your home for adoption; and children for whom you are legal guardian. Such dependent children will remain eligible until the end of the calendar month in which they turn age 26 and they may live in your household or elsewhere, are not subject to student status, marital or dependents requirements. In such cases where your dependent child is enrolled in active medical benefits by the SOI Health Plan, and medical coverage past the age of 26 is extended due to applicable law, active dental and vision coverage will be extended for the same time frame that extended medical coverage applies. Please see the Summary Plan Description (SPD) for more information regarding dependent eligibility. Please be advised that in circumstances where an employee submits an eligible application requesting coverage for a dependent who has a different last name than the employee, SOI will require documentation that proves the dependent is qualified to be covered by the plan. Examples of required documentation include a copy of a marriage certificate, birth certificate or adoption or placement agreement. Enrollments will not be processed until all required documentation has been received, at which time, eligible employees and their eligible dependents will be enrolled back to their original effective date and back premiums will be collected from the employee in a lump sum. In the case of a discrepancy between the information contained in this document and the plan document, the plan document governs. This document does not describe the plan limitations and exclusions that can be found in the Summary Plan Description. To verify benefits, eligibility, or claim status, please contact Guardian or EyeMed. -Page 2-

4 When Can I Join the Plan? Eligible employees may elect coverage as soon as they are hired or within 30 days of becoming eligible. For new clients, employees who are hired on or before a client s health care effective date with SOI (generally the first of a month) are eligible as of that date regardless of how long they have been employed. In other words, the waiting period is waived for all employees on a client s original health care effective date with SOI. For employees hired after a client is first effective on the SOI Health Plan, benefits will become effective on the first day of the month following 90 days of regular, active, full-time employment, except for those employees who are residents of Hawaii or rth Carolina (as determined by the home address on file with SOI). As required by law, benefits will become effective the first of the month following the date of hire for Hawaii residents. Benefits will become effective on the 90 th day of regular, active, full-time employment for rth Carolina residents. If an employee s waiting period ends on the first day of a month, the employee will be eligible for coverage that day, not the first day of the next month. The decision to elect or waive coverage should be weighed carefully because employees cannot change their election until the plan s annual open enrollment period unless they experience a qualifying event. Once a year the plan holds an Open Enrollment Period during which an eligible individual may apply for or adjust coverage with the SOI Dental and Vision Plan. The open enrollment period for SOI takes place annually, from January 15 th through February 14 th, for a March 1 st effective date. If an enrolled employee does not submit a change form during open enrollment, their benefits plan selection and coverage level will not change. What is a Preferred Provider Organization (PPO)? A PPO Plan gives its members access to a panel or network of providers who have agreed to treat members at a reduced contracted rate. In a PPO plan, the participant has the choice of either seeing a network provider or an out-of-network provider. If members choose to be treated by an in network provider, their cost for services will be substantially lower. If an out-of-network provider is used, benefits will be paid at a significantly reduced rate. Both the SOI Dental and Vision plans utilize a PPO network of providers. Referrals by PPO providers to non- PPO providers will be considered at the "out-of-network" level. This means that your benefits will be paid at a reduced rate. In order to receive PPO benefits, ask your provider to refer you to listed PPO providers. It is your responsibility to verify whether or not a provider participates in the network. You should always verify a provider's network participation prior to your appointment. This can be done by calling Guardian and EyeMed via the SOI Benefits Hotline at (888) or by accessing the online directory for the plans. SOI has provided links to the directories on our website, on the Employee Resources page. More information about online directories can be found in the book under the section titled How Do I Locate Participating Providers? Qualifying Events/Status Changes In order to offer our plan on a pre-tax basis, SOI must comply with the IRS Section 125 guidelines. This means that we must limit the circumstances under which an employee can join or leave our plan. Once an employee has elected to participate in the plan, he or she cannot change benefits or terminate the plan except during Open Enrollment. Employees who waive coverage cannot change their minds and join the plan until Open Enrollment. Employees who decide to join the plan during Open Enrollment will be considered late enrollees. There are some important exceptions to this restriction. The law does allow for people to make changes to their elections if the change is due to a qualified family status change or life event. Qualifying events include the following: the employee s marriage, divorce or legal seperation; the birth or adoption or legal guardianship of the employee s child; death of an employee s SOI Health Plan eligible and federally recognized dependent; In the case of a discrepancy between the information contained in this document and the plan document, the plan document governs. This document does not describe the plan limitations and exclusions that can be found in the Summary Plan Description. To verify benefits, eligibility, or claim status, please contact Guardian or EyeMed. -Page 3-

5 a court order is issued to provide or discontinue coverage; there is a significant change in the employee s or his/her spouse s cost of health coverage; there is a significant change in the benefits offered by the employee s or spouse s employer; a change in the employee s or spouse s employment status; gain or loss of other coverage including coverage under a Children s Health Insurance Program (CHIP). When a participant experiences a qualifying event only certain enrollment changes are allowed. Generally speaking, allowable changes are only those that are consistent with your change in status. In other words, you may only change your election if a change in status causes you or your SOI Health Plan eligible and federally recognized dependent to gain or lose eligibility for coverage under this or another similar plan. The election change must correspond with the effect on coverage. While many of the qualifying events listed above will allow an eligible employee to change coverage level (i.e., employee only to family or family to employee only), cancel coverage or join the plan, not all qualifying events allow the same enrollment changes. For more information on your qualifying event and allowable enrollment changes, please contact SOI. Regardless of the type of qualifying event experienced, an employee who elects a change must notify SOI within 30 days of the event (or 60 days in the case of gain or loss of CHIP coverage) by submitting a completed Benefits Change Form to the SOI Benefits Department. Documentation proving that a qualifying event has occurred MUST accompany the Health Plan Change Form. Any eligible forms received after an employee s qualifying event will cause a retroactive change to coverage and any applicable change in premiums will be deducted in a lump sum on your next paycheck. How Do I Locate Participating Providers? Dental Plan Providers The SOI Dental Plan utilizes the Guardian Dental Guard Preferred Network and dental claims are processed by Guardian. Guardian s network is one of the largest dental PPO networks in the country. The Guardian dental provider directory can be accessed online through the SOI website at From that page click on the link to Employee Resources and then click on the link in the SOI Dental Plan section of the page. This will take you to a link to the Guardian website that will allow you to search for providers. You can also access the Guardian provider directory by following these simple steps: 1. Visit 2. Once you receive your Dental ID Card, you can register for online account access, or prior to enrollment click on the 'Site Index' link found in the bottom right hand corner of the web page. 3. In the Group Benefits section, click on Provider Online Search 4. Click on the Find a Dentist link 5. Select PPO from the Select A Plan drop down box 6. Enter your specific search criteria (zip code or street address) 7. Select the Dental Guard Preferred network in the Select Your Dental Network drop-down box and proceed with entering your search criteria. Vision Plan Providers The SOI Vision Plan utilizes the EyeMed Access network. EyeMed s network includes a choice of thousands of nationwide providers. The EyeMed Access Network provider directory can be accessed online through the SOI website at From that page click on the Employee Resources link and click on the link in the SOI Vision Plan section of the page. Carrier Contact Information Dental Plan Contact Information In order to verify dental benefits, access a provider, determine eligibility or claim status or for more information regarding the SOI Dental Plan, please contact Guardian via the SOI Benefits Hotline by calling (888) , and selecting option 4. You can request information on your coverage by providing your specific information or one of the following group numbers: Policy Holders & Members Covered by Nevada or Virginia Residents All Other Participants In the case of a discrepancy between the information contained in this document and the plan document, the plan document governs. This document does not describe the plan limitations and exclusions that can be found in the Summary Plan Description. To verify benefits, eligibility, or claim status, please contact Guardian or EyeMed. -Page 4-

6 Network providers should submit claims for you. All other dental claims should be submitted to the following address: SOI Health Plan PO Box Charlotte, NC Vision Plan Contact Information In order to verify vision benefits, access a provider, determine eligibility or claim status or for more information regarding the SOI Vision Plan, please contact EyeMed via the SOI Benefits Hotline by calling (888) , and selecting option 3. You can request information on your coverage by providing your specific information or one of the following group numbers: Policy Holders & Members Covered by Nevada or Virginia Residents All Other Participants Network providers should submit claims for you. All other vision claims should be submitted to the following address: EyeMed 4000 Luxottica Place Mason, OH All claims must include the following information: the patient s name; the insured member s name and Member ID or Social Security Number; the provider s name, address, telephone number, and degree; the provider s federal tax id number; the diagnosis; the services performed and/or supplies provided; details of the charge for each supply or service Failure to supply all information may result in a delay or denial of the claim. In order to obtain status on a claim, call the appropriate carrier at the numbers referenced above. You will need to provide the customer service representative with the following information: the insured member s Member ID or Social Security Number; the patient s name; the provider s name; the date of service; the amount of the claim Once your claim has been processed, you will receive an explanation of benefits (EOB) electronically or in the mail based on your on-file communication preferences. This is a statement showing you how benefits were paid on your claim. If you have any questions about your EOB, or feel your claim was handled incorrectly, please contact the appropriate carrier s Customer Service Department. A customer service representative can answer your questions and, if necessary, adjust the claim. Frequently Asked Questions We will attempt to answer some questions you may have regarding the SOI Dental and Vision Plans. If your questions are not answered here, please contact the SOI Customer Care Department at or Guardian and EyeMed at the numbers previously listed. 1) Do I have to change providers? t necessarily. SOI s Dental and Vision programs access some of the largest national networks of participating providers. You may call and determine if your provider is a member of the network. If your provider isn t a member, you will still be able to access care at a reduced reimbursement rate. Please remember, you will receive the highest level of benefit if you stay within the network. Changing providers is a choice that you can make at any time. In the case of a discrepancy between the information contained in this document and the plan document, the plan document governs. This document does not describe the plan limitations and exclusions that can be found in the Summary Plan Description. To verify benefits, eligibility, or claim status, please contact Guardian or EyeMed. -Page 5-

7 2) Where should I send claim forms? One of the advantages of a visit to a preferred provider is that the provider will submit the claim on your behalf. Visits to providers outside the network will require submission of a claim form. Please be advised that most out-of-network providers expect payment when services are rendered and may make claim submission your responsibility. In the event you need to submit a claim form, the address for mailing claims is printed on your Dental/Vision Plan ID card. 3) Will I get a new ID cards?. You will receive new ID cards after initial enrollment in the SOI Dental and/or Vision Plan. When you receive your cards, please carefully review them to ensure your name, plan selection and other data are correct. Please report any necessary corrections to the SOI Customer Care Department at (888) ) How many ID cards will I receive? Members enrolling in the Guardian dental plan will receive two ID cards in the member s name. Employees enrolling in the EyeMed vision plan will receive one ID card if they are enrolled in individual coverage and two ID cards if they cover any family members in addition to themselves. 5) Who should I call if I have a question about a claim? Questions about dental claims should be directed to Guardian via the SOI Benefits Hotline at (888) 8FOR-SOI or (888) , option 4. Questions about vision claims can be answered by calling the same number and selecting option 3. 6) What if I don t receive an ID card? If you have not received your ID card within two weeks of your dental or vision effective date, or the date you submitted your application to SOI, please contact the appropriate carrier via the SOI Benefits Hotline at (888) 8FOR-SOI or (888) You can also access temporary vision plan ID cards online via the EyeMed website. Replacement dental plan ID cards can be requested online via the Guardian website, but temporary cards are not currently available online. 7) What if I need to change my address? Change of address information must be submitted in writing to SOI. An address change form can be accessed on the SOI website at under the Employee Resources section. Please contact the SOI Customer Care Department at (800) for further instructions. 8) When will deductions for coverage begin? Deductions will begin on your first paycheck of the month in which your coverage begins or the first paycheck after the date we process your eligible enrollment form if the form is submitted after your effective date. If an eligible enrollment form is received after your effective date, your coverage will be set-up retroactively and any missed premiums will be deducted from your next paycheck in a lump sum. 9) Where should I submit my enrollment forms? If this information is being presented to you as part of an enrollment meeting, please return your enrollment applications to the person conducting your meeting. Otherwise, please mail completed applications back to SOI to the following address: SOI Benefits Department PO Box Charlotte, NC Or for faster processing, fax or completed applications to SOI at: (704) / health@soi.com 10) When can I elect to make changes to my coverage? The SOI Dental and Vision Plan is administered under the guidelines of Section 125 of the IRS code, which allows deductions for federally recognized dependents to be taken on a pre-tax basis, but also limits changes to the plan to an annual Open Enrollment period. The Open Enrollment period is held from January 15 th through February 14 th, and all changes made during Open Enrollment go into effect March 1 st. Open Enrollment is the only time during the year eligible employees can elect to make changes, additions, or drop coverage unless they experience a qualifying event. 11) What is a qualifying event? The IRS outlines a list of life events that are qualified to allow employees to make changes to their pre-tax plans. Please refer to the Qualifying Events/Status Changes section of this booklet for more information about these events. Please be advised that the IRS does not provide a qualifying event for inability to afford premiums unless there is a significant change in the premiums charged to employees. This means that once an employee elects the plan, if premiums are level, coverage cannot be dropped unless it is during Open Enrollment or due to a qualifying event. In the case of a discrepancy between the information contained in this document and the plan document, the plan document governs. This document does not describe the plan limitations and exclusions that can be found in the Summary Plan Description. To verify benefits, eligibility, or claim status, please contact Guardian or EyeMed. -Page 6-

8 12) How do I prove that I had a qualifying event? All enrollment changes due to a qualifying event must be accompanied by proof of the qualifying event. All qualifying event documentation must include pertinent information about the event including the date of the event and the employee s name. Some examples of required documentation include: Birth Certificate or Certificate of Live Birth Adoption Certificate Divorce or Legal Separation Documents HIPAA Certificate Court Order for Dependent Coverage Marriage Certificate Certificate of Creditable Coverage Death Certificate More information regarding qualifying events can be found in your Summary Plan Description. 13) Will I receive a Summary Plan Description (SPD)?. Once you enroll in the SOI Dental or Vision Plan, you will receive a Healthcare Summary Plan Description with detailed plan information. Please retain your copy in a safe place and refer to it when you have questions about your dental and vision plan reimbursements, how to file a claim, etc. 14) Can I receive credit towards my dental waiting periods?. Members who had prior dental coverage can receive credit towards their dental waiting periods as long as any break in coverage from the termination date of your prior plan and the start of your SOI dental coverage is not longer than 63 days. If your prior plan provides a certificate of creditable dental coverage, that certificate can be forwarded to the SOI Dental Plan so that the appropriate credit may be applied to your coverage with the SOI Dental Plan. Please forward proof of prior dental coverage for each of your covered family members to SOI via fax or at (704) or hipaa@soi.com. 15) Do the SOI Dental and Vision Plans have coordination of benefits provisions?. If this plan is secondary coverage to another health plan, it may make additional payment for covered expenses after any applicable deductible is met. This additional payment is made only to bring the total payment by the combined plans to the amount that this plan would have paid if it were the only coverage. Therefore, dual enrollment in two plans that cover the same types of benefits (i.e. two dental plans or two vision plans) should be considered carefully as the benefits may not outweigh the costs. 16) When will my active SOI Dental and Vision Plan coverage end? Active coverage in the SOI Dental and Vision Plan will terminate on the date that your active employment or eligibility for the dental and vision plan ends (for example, the date you move from full-time to part-time employment). Coverage will be extended to the end of the month for certain TX residents and/or your paid through date as required by law. 17) Can I continue coverage after I am no longer eligible for group coverage? If you lose coverage under the Plan for certain reasons, such as a reduction in the hours you work, death of a spouse, or divorce, you may be entitled to obtain continued coverage under COBRA or a similar applicable state mandated law. Please refer to your SPD for more details on coverage extension options. However, please note that if your worksite group ceases participation in the SOI Dental and Vision Plan, COBRA or similar coverage extension will also terminate at that time. If your worksite employer ceases participation in the plan you may be able to continue coverage under any replacement plan applicable to your worksite group. Please note that published rates for all plans may include an administrative fee that may be charged by SOI. In the case of a discrepancy between the information contained in this document and the plan document, the plan document governs. This document does not describe the plan limitations and exclusions that can be found in the Summary Plan Description. To verify benefits, eligibility, or claim status, please contact Guardian or EyeMed. -Page 7-

9 Plan Type: Dental PPO Plan SOI GUARDIAN DENTAL PLAN Network Name: Dental Guard Preferred All Covered Markets In-Network Out-Of-Network PLAN FEATURES Member Expenses Member Expenses Per Member $0 $50 Calendar Year Deductible Family Maximum $0 $150 Preventive Services Covered 100% Covered 100% Basic Services 10% 20% (after deductible) Major Services (12 month waiting period applies**) 40% 50% (after deductible) Dental Calendar Year Maximum $1,500* $1,000* Orthodontia (24 month waiting period applies**) 40% 50% Orthodontia Lifetime Maximum $1,500* $1,000* * All PPO and n-ppo benefit maximums are combined. **The waiting periods can be waived with proof of prior dental coverage Plan Type: Vision PPO Plan SOI EYEMED VISION PLAN Network Name: Access All Covered Markets In-Network Out-Of-Network PLAN FEATURES Member Expenses Reimbursement Maximums Examination with Dilation a $10 co-pay $35 reimbursement max Single Vision Lenses a $10 co-pay $25 reimbursement max Bifocal Lenses a $10 co-pay $40 reimbursement max Trifocal Lenses a $10 co-pay $55 reimbursement max Frames b $100 allowance plus 20% off $50 reimbursement max charges over $100 Standard Contact Lens Fit & Follow Up d $55 maximum member cost NA Premium Contact Lens Fit & Follow Up e 10% off retail price NA Lens UV Coating a $15 additional co-pay c NA Lens Tint (Solid & Gradient) a $15 additional co-pay c NA Standard Scratch Resistance Lens a $15 additional co-pay c NA Standard Polycarbonate Lens a $40 additional co-pay c NA Standard Anti-Reflective Lens a $45 additional co-pay c NA Standard Progressive Lens (add-on to Bifocal) a $75 additional co-pay c $40 reimbursement max Premium Progressive Lens (add-on to Bifocal) a $75 additional co-pay c, 80% of $40 reimbursement max charge less $120 allowance Other Lens Add-Ons and Services a 20% discount NA Conventional Contact Lenses (materials only) a $115 allowance plus 15% off $92 reimbursement max charges over $115 Disposable Contact Lenses (materials only) a $115 allowance $92 reimbursement max Medically Necessary Contact Lenses a Paid in full $200 reimbursement max LASIK or PRK from U.S. Laser Network 15% off retail price or 5% off N/A promotional price Members will receive a 20% discount on remaining balances beyond plan coverage at network providers which may not be combined with any other discounts or promotional offers. The discount does not apply to professional services or contact lenses. Retail prices may vary by location. Lost or broken materials are not covered a Examinations and lenses OR contacts are covered once every 12 months. b Frames are covered once every 24 months. c In addition to standard lens co-pay d Standard Contact Lens Fitting spherical clear contact lenses in conventional wear and planned replacement (includes but is not limited to disposable, frequent replacement, etc.) e Premium Contact Lens Fitting all lens designs, material and specialty fittings other than Standard Contact Lenses (includes toric, multifocal, etc.) In the case of a discrepancy between the information contained in this document and the plan document, the plan document governs. This document does not describe the plan limitations and exclusions that can be found in the Summary Plan Description. To verify benefits, eligibility, or claim status, please contact Guardian or EyeMed. -Page 8-

10 Type of enrollment NEW OPEN ENROLLMENT * DENTAL & VISION BENEFITS ELECTION FORM THIS SECTION SHOULD BE FILLED OUT BY YOUR EMPLOYER EMPLOYEE TYPE WORKSITE EMPLOYER NAME CLIENT# *All other changes should be submitted on a Benefits Change Form For Open Enrollment terminations, use the other side of this form. Employee Last Name First Name Middle Initial Social Security Number Date of Birth Home Address City State Zip County Have you had an address change? NO YES Gender SOI Employment Date Preferred Language ENGLISH SPANISH OTHER: Communication Disability? NO YES/Type: DENTAL LEVEL Employee + Child(ren) VISION LEVEL Employee + Child(ren) Employee Only Family Employee Only Family Employee + Spouse ne Employee + Spouse ne DEPENDENT INFORMATION: Please note: Coverage for qualified domestic partners (D.P. s) also requires completion of the Domestic Partnership Declaration Form Dependent s Full Name (First, Middle Initial, Last) Dental Coverage Vision Coverage Gender Social Security Number Date of Birth Preferred Language Communication Disability? Spouse/D.P. Child Child Child Child AUTHORIZATION - YOU MUST CHECK ONE OF THE FOLLOWING (SHOULD NOT BE USED FOR TERMINATION OF COVERAGE): YES, I elect to participate in the SOI Dental and Vision Plan. I understand my deductions will be taken on a pre-tax basis and I will not be able to change or terminate my elections until Open Enrollment unless I have a coordinating Change in Family Status as defined by Section (125) of the Internal Revenue Code. I understand that if I have a new dependent as a result of marriage, birth, adoption or placement for adoption, that I may be able to enroll my new dependent(s) at that time, provided that I request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. Additionally, I understand that there are some important exclusions to the benefits payable under this plan as outlined in the Certificate of Coverage. NO, I do not elect to participate in the SOI Dental and Vision Plan. I have been offered an opportunity to participate in the STRATEGIC OUTSOURCING, INC. Dental and Vision Plan and have decided NOT to take advantage of this offer. I waive my right to participate. Are you declining enrollment in the STRATEGIC OUTSOURCING, INC. Dental and Vision Plan for yourself and/or your dependents due to coverage through another dental or vision plan? If you are declining enrollment due to other coverage, please attach proof of your other coverage to this form. Please te: If you are declining enrollment for yourself or your dependents (including your spouse) because of other dental and/or vision 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 (60 days in the case of loss of CHIP coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption or placement for adoption By signing this application, I authorize persons or entities that have any medical, other records or knowledge of me or my dependents to release such information to the SOI Dental and Vision Plan (or other affiliated carrier or reinsurer). These include any licensed physician, medical practitioner, hospital, clinic or other medical or medically related provider; insurer, employer, other organization, institution, or person. I also authorize the SOI Dental and Vision Plan at its sole discretion, to release claims information to other insurers, my employer (upon request), or my employer's designee (upon request). This claims information includes specific medical information on me or my dependents. These releases specifically include, but are not limited to, authorization to release any and all medical records, and information about, associated with, or with reference to certain conditions. These conditions include positive test result for HIV infection, ARC, AIDS, alcohol or drug dependency, and mental and nervous disorders. I authorize the SOI Dental and Vision Plan to exchange benefit information with any insurance company, organization or individual to determine if the coordination of benefits applies for me and my dependents. When an overpayment is made, I authorize the SOI Dental and Vision Plan to recover the excess from any person or entity that received it. Employee Signature Date For Office Use Only: Effective Date Processed By In order to be eligible for processing all election forms MUST be submitted to the SOI Benefits Department at PO Box ; Charlotte, NC 28224; OR they may be faxed to (704) or ed to health@soi.com. -Page 9-

11 OPEN ENROLLMENT TERMINATION FORM This form should ONLY be used for termination or waiver of benefits from January 15, 2012 through February 14, 2012 during SOI s Annual Open Enrollment Period THIS SECTION SHOULD BE FILLED OUT BY YOUR EMPLOYER EMPLOYEE TYPE WORKSITE EMPLOYER NAME CLIENT# Last Name First Name Middle Initial Social Security Number Home Address City State Zip County Have you had an address change? NO YES SOI Employment Date Preferred Language Communication Disability? ENGLISH SPANISH OTHER: NO YES/Type: AUTHORIZATION: By signing below I elect to terminate or waive all dental and vision benefits for myself and all eligible family members effective March 1, I have been offered an opportunity to participate in the STRATEGIC OUTSOURCING, INC. Health Plan and have decided to waive or terminate my participation and NOT to take advantage of this offer. I understand that if I am waiving or terminating enrollment for myself or my dependents (including my spouse) because of other health insurance coverage I may, in the future, be able to enroll myself or my dependents in this plan provided that I request enrollment within 30 days after my other coverage ends. Additionally, if I have a new dependent as a result of marriage, birth, adoption or placement for adoption, I may be able to enroll myself and my dependents, provided that I request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. Finally, I understand that if I complete, sign & submit both an Election and Termination form during Open Enrollment (January 15, 2012 February 14, 2012) I will be enrolled or terminated from benefits as elected on the latest date. Employee Signature Date (only for use between 1/15/2012-2/14/2012) For Office Use Only Effective Date Processed By In order to be eligible for processing all applications MUST be submitted to the SOI Benefits Department at PO Box ; Charlotte, NC 28224; OR they may be faxed to (704) or ed to health@soi.com. -Page 10-

12 DENTAL AND VISION CHANGE FORM This form should NOT be used from January 15, 2012 through February 14, 2012 for changes due to SOI s Annual Open Enrollment Period THIS SECTION SHOULD BE FILLED OUT BY YOUR EMPLOYER EMPLOYEE TYPE WORKSITE EMPLOYER NAME CLIENT# Employee Last Name First Name Middle Initial Social Security Number Home Address City State Zip County Have you had an address change? NO YES Gender SOI Employment Date Preferred Language Communication Disability? FEMALE ENGLISH SPANISH OTHER: NO YES/Type: MALE SOI s Dental and Vision Plan deductions are taken on a pre-tax basis through our Section 125 Plan. Therefore, Federal regulations dictate when a plan participant may add, change or drop coverage. Please refer to your Certificate of Coverage, Summary Plan Description or other plan information regarding these guidelines before requesting any change to your coverage. Any change in coverage must be made within 30 days of the associated qualifying event (or 60 days in the case of gain or loss of CHIP coverage). You must supply appropriate documentation containing the date of the qualifying event with any request to change your plan type or coverage level. Examples of required documentation are listed below. ADDING/CHANGING COVERAGE FOR DEPENDENTS (Please note that in order to add coverage for an employee an enrollment form must be completed) I wish to add a dependent to the dental and/or vision plan to begin participation during the plan year. I have experienced the following Qualifying Event: Birth, adoption or placement for adoption of a child; requires copy of birth certificate, certificate of live birth or adoption paperwork Court order for dependent coverage; requires copy of the court order Employee, Spouse or Dependent loses other coverage; requires documentation from the previous dental or vision carrier including name(s) of covered member(s) and each member s benefit termination date Marriage; requires copy of marriage certificate DROPPING COVERAGE I wish to drop coverage for myself or a dependent. I have experienced the following Qualifying Event: Divorce, or legal separation; requires copy of divorce or legal separation documents Death of a spouse or dependent; requires copy of the death certificate Employee, Spouse or Dependent gains other coverage; requires documentation from the new dental or vision carrier including name(s) of covered member(s) and each member s benefit effective date PLEASE INDICATE THE TYPE OF DOCUMENTATION SUPPLIED TO VERIFY YOUR QUALIFYING EVENT: COVERAGE INFORMATION PLEASE NOTE: EMPLOYEES WISHING TO ADD COVERAGE FOR THEMSELVES MUST COMPLETE A BENEFITS ELECTION FORM. ALSO, AN EMPLOYEE MUST BE ENROLLED IN A PLAN IN ORDER TO PROVIDE COVERAGE IN THAT PLAN TO THEIR DEPENDENTS. Full Name (First, Middle Initial, Last) Dental Coverage Vision Coverage Gender Social Security Number Date of Birth Preferred Language Communication Disability? Employee Spouse Child Child Child Child Employee Signature Date For Office Use Only: Effective Date Processed By In order to be eligible for processing all change forms MUST be submitted to the SOI Benefits Department at PO Box ; Charlotte, NC 28224; OR they may be faxed to (704) or ed to health@soi.com. -Page 11-

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14 DOMESTIC PARTNERSHIP DECLARATION FORM Employees wishing to cover a qualified domestic partner should complete this form in addition to a Benefits Election Form THIS SECTION SHOULD BE FILLED OUT BY YOUR EMPLOYER EMPLOYEE TYPE WORKSITE EMPLOYER NAME CLIENT# Employee Last Name First Name Middle Initial Employee Social Security Number Domestic Partner Last Name First Name Middle Initial Domestic Partner Social Security Number Our Home Address City State Zip County Have you had an address change? NO YES This Declaration is provided to help establish eligibility for certain SOI health benefits. It is not to be used for purposes of illegal discrimination or harassment. It does not expand or alter the terms of any benefit plan or guarantee plan enrollment. Any alterations to the printed text of this Declaration or incompleteness will render it ineffective. 1. We, the undersigned Employee and Domestic Partner, each acknowledge, certify and affirm that either (check one) Our relationship is a domestic partnership, civil union, same-sex marriage, or other formal relationship similar to marriage that is officially recognized by the laws of our domicile state (which will be referred to on this form as a domestic partnership ); OR We meet ALL of the following criteria: Our domestic partnership began prior to the date of this Declaration. We are each-other s sole domestic partner and intend to remain so indefinitely. Neither of us is currently married to or legally separated from someone other than the other. Neither of us has had another domestic partner in the six months preceding this Declaration. We are both at least 18 years of age and competent to consent to contract. We are not related by blood to a degree of closeness that would prohibit legal marriage in our domicile state. We have resided together for at least six months prior to this Declaration and intend to do so indefinitely. We have not formed a domestic partner relationship solely to obtain benefits coverage. We are engaged in a committed relationship of mutual caring and support and are jointly responsible for our common welfare and living expenses. Also, our interdependence is demonstrated by at least three of the following (check as appropriate and attach substantiating documents): Common ownership or leasehold of our primary home Designation of each partner as the other s primary beneficiary for Common ownership of a motor vehicle. life insurance, retirement benefits, or for purposes of a will. Common primary residence address of record. Appointment of each partner as the other s durable power of Joint bank account or credit account. attorney or health care power of attorney. 2. We, the undersigned Employee and Domestic Partner, understand that: We are both required to notify Strategic Outsourcing, Inc. within 31 days if there is any change in our domestic partnership status as attested to in this Declaration that constitutes a termination of our domestic partnership relationship (for example, by reason of death of a partner, no longer sharing a home address, or ending of the relationship). To provide this notice contact Strategic Outsourcing, Inc. at (800) and request a Termination of Domestic Partnership form. Children of the Domestic Partner are eligible for coverage when they are unmarried, primarily dependent on the Employee for support, and otherwise meet the eligibility requirements of an applicable benefits plan (age, school, etc.). Any coverage for the Domestic Partner or the Domestic Partner s dependents obtained in connection with this Declaration will terminate no later than on the date the domestic partnership relationship ends. Any false, incomplete, or misleading information provided on this Declaration, and any failure to notify Strategic Outsourcing, Inc. of changes to the information on this Declaration, could result in denial of benefits or eligibility, legal liability, and employment discipline up to and including termination of employment. This Declaration may have legal and tax implications for us. We have relied on our own judgment in filing this Declaration and understand that we should consult our own attorneys and tax advisors if we have any questions. Strategic Outsourcing, Inc. respects the privacy of benefits participants, however, the information in this Declaration may be shared with certain others, including for purposes of plan administration and legally-compelled disclosures. Federal law and some state laws do not recognize domestic partners, civil unions, or same-sex marriages. Accordingly, federal COBRA continuation and certain other benefits are not available for Domestic Partners and their dependents, and their premiums will be subject to some payroll taxes. We affirm, under penalty of perjury, that the statements in this Declaration are true and correct. Employee Signature Date of Birth Signature Date Domestic Partner Signature Date of Birth Signature Date For Office Use Only: Effective Date Processed By In order to be eligible for processing all domestic partnership declaration forms MUST be submitted to the SOI Benefits Department at PO Box ; Charlotte, NC 28224; OR they may be faxed to (704) or ed to health@soi.com. -Page 13-

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16 DOMESTIC PARTNERSHIP TERMINATION FORM This notice may be signed by either or both persons in the domestic partnership relationship, but only one signature is required. THIS SECTION SHOULD BE FILLED OUT BY YOUR EMPLOYER EMPLOYEE TYPE WORKSITE EMPLOYER NAME CLIENT# Employee Last Name First Name Middle Initial Employee Social Security Number Domestic Partner Last Name First Name Middle Initial Date Domestic Partnership Terminated Employee Home Address City State Zip County Have you had an address change? NO YES This Declaration is provided to help establish eligibility for certain SOI health benefits. It is not to be used for purposes of illegal discrimination or harassment. It does not expand or alter the terms of any benefit plan or guarantee plan enrollment. Any alterations to the printed text of this Declaration or incompleteness will render it ineffective. 1. We, the undersigned Employee and Domestic Partner, each acknowledge, certify and affirm that either (check one) Our relationship was a domestic partnership, civil union, same-sex marriage, or other formal relationship similar to marriage that is officially recognized by the laws of our domicile state (which will be referred to on this form as a domestic partnership ); OR Our relationship was not a domestic partnership officially recognized by the laws of our domicile state, therefore, we agree to use the date on which the relationship no longer met or will not meet all of the following criteria: We are each-other s sole domestic partner and intend to remain so indefinitely. Neither of us is currently married to or legally separated from someone other than the other. We are not related by blood to a degree of closeness that would prohibit legal marriage in our domicile state. We reside together and intend to do so indefinitely. We have not formed a domestic partner relationship solely to obtain benefits coverage. We are engaged in a committed relationship of mutual caring and support and are jointly responsible for our common welfare and living expenses. Also, our interdependence is demonstrated by at least three of the following Common ownership or leasehold of our primary home Designation of each partner as the other s primary beneficiary for life Common ownership of a motor vehicle. insurance, retirement benefits, or for purposes of a will. Common primary residence address of record. Appointment of each partner as the other s durable power of attorney or Joint bank account or credit account. health care power of attorney. 2. We, the undersigned Employee and Domestic Partner, are hereby advised that: Coverage for the Domestic Partner and any children of the Domestic Partner will terminate no later than the date on which the domestic partnership terminates. This may result in retroactive termination of coverage and denial of claims even such claims were approved prior to the receipt and processing of this notice. Federal law does not recognize domestic partnerships, civil unions, same-sex marriages or the like (even if sanctioned by state law); accordingly federal COBRA continuation is not available to a Domestic Partner or a Domestic Partner s children. Any false, incomplete, or misleading information provided on this tice or to the plan could result in denial of benefits or eligibility, legal liability, and employment discipline up to and including termination of employment. The submission of this tice may have legal and tax implications for you. You have relied on your own judgment and understand that you should consult your own attorneys and tax advisors if you have any questions. Strategic Outsourcing, Inc. respects the privacy of benefits participants, however, the information in this tice may be shared with certain others, including for purposes of plan administration and legally-compelled disclosures. It is your responsibility to update information such as (but not limited to) the status of your domestic partnership relationship and your current address. Strategic Outsourcing, Inc. and any others involved in the administration of the plan may rely on the information you have provided in this tice and elsewhere and have no obligation to further verify such information; we are not liable for any actions taken in reliance on information you provide. If there is a dispute relating to the status of the domestic partnership relationship as it pertains to participation in or benefits under the plan, it must be submitted in writing to Strategic Outsourcing, Inc. which will adjudicate it as an appeal of benefits (all rights to interpret the terms of the plan in the discretion reserved to a plan administrator to the fullest extent of the law are reserved). This tice is provided to help establish eligibility for certain benefits. It is not to be used for purposes of illegal discrimination or harassment. It does not expand or alter the terms of any benefit plan or guarantee plan enrollment. Any alterations to the printed text of this tice or incompleteness will render it ineffective. Signatures hereon submitted by facsimile, scanned image, or other electronic means, or in counterparts, will have the same effect as if received in a single, hard copy original form. I/we affirm, under penalty of perjury, that the statements in this tice are true and correct. Employee Signature Employee Date of Birth Employee Signature Date Domestic Partner (DP) Signature (not required) DP Date of Birth DP Signature Date (not required) For Office Use Only: Effective Date Processed By In order to be eligible for processing all domestic partnership termination forms MUST be submitted to the SOI Benefits Department at PO Box ; Charlotte, NC 28224; OR they may be faxed to (704) or ed to health@soi.com. -Page 15-