Employee Name: Date of birth: 2014 Carrols Corporation Employee Benefits Open Enrollment Form Only Complete if you are changing or adding benefits Effective Date: EmpID/POS ID 01/01/2014 Complete Address: Deadline 11/30/2013 Medical Plan BC/BS PPO Plan 1 Dental Plan EBS Benefit Solutions Medical Plan BC/BS PPO Plan 2 Supplemental Life Insurance One Times Basic Coverage Two Times Basic Coverage Three Times Basic Coverage Medical Plan BC/BS PPO Plan 3 Vision Plan VSP Dependent Life Insurance spouse child Wage Continuation Short/Long Term Disability Option 1 $10,000 $2,500 I wish to enroll Option 2 $10,000 $5,000 Option 3 $20,000 $10,000 Retirement Savings Plan 401(k) To enroll please contact Benefits Department Flexible Spending Account FSA *FSA requires annual re-enrollment* Complete separate form I wish to enroll GO TO PAGE 2
PAGE 2 2014 Carrols Corporation Employee Benefits Open Enrollment Form Eligible dependents under the Medical program may continue coverage up to age 26 regardless of student status or marital status. NOTE: The definition of eligible dependents under the Dental,Vision and Dependent life Insurance programs is your legal spouse, and/or unmarried dependent children up to age 19. Coverage for unmarried dependent children may continue up to age 25, providing your dependent is an unmarried, full time registered student at an institution of higher learning. If your eligible dependent child is between 19 & 25 you must complete the attached student certification form. Failure to provide this completed form will result in denial of coverage for your eligible dependent(s) enrolled in the Dental, Vision and Dependent Life Insurance benefit programs. Only Complete if you are changing or adding benefits -Please Print Employee Name: Effective Date: 01/01/2014 Dependents Full Name Date of birth Spouse/ Child Date of Marriage Full time Student Y/N Gender M/F Medical Dental Vision Dependent Life If adding a spouse or dependent with a different last name than the employee, documentation must be provided. Documentation includes a marriage certificate, birth certificate or domestic partner verification forms. PRE-TAX (BEFORE TAX) Contribution election Your employee contributions for the medical, dental, vision and supplemental life plans will be deducted from your pay on a pre-tax basis unless you check below DO NOT deduct my employee contributions for the medical, dental, vision and supplemental life plans on a pre-tax basis. Important: If you wish to have ONLY your supplemental life employee contributions deducted on a Post Tax basis (keeping medical/dental/vision on a pre tax basis) check below I wish to have my supplemental life insurance deductions on a post tax basis I authorize Carrols Corporation to deduct from my wages my employee contribution(s) for the cost of the benefits elected on this form, as well as my subsequent changes in coverage for which I am eligible. This authorization will remain in effect until revoked by me at Open Enrollment, or at the time I am no longer eligible to participate. I further understand that other than Open Enrollment, I can not make any changes to the benefits selected unless the changes are a result of a qualified lifestyle change. Should I terminate employment or become ineligible to participate in the programs, I understand that the Company will deduct my contributions for the following plans: Medical, Dental, Vision, Supplemental Life and Dependent Life Insurance through the end of the month. AUTHORIZATION: PLEASE READ CAREFULLY, THEN SIGN AND DATE BELOW: Employee Signature: Date: Return this completed form, along with the other applicable forms (Other Insurance Form, Dependent Certification Form, Life Insurance Beneficiary Form and the Flexible Spending Account form) to the Employee Benefits Department by the deadline stated below. Deadline November 30, 2013. Fax pages 1 & 2 The fax number is 315-410-7357 e-mail 2014openenrollment@carrols.com
FORM NUMBER: BCBSCOB12 BlueCross BlueShield of Central New York Medical Plan OTHER INSURANCE INFORMATION Coordination of Benefits Please Print: Employee s name: Employee s Social Security number: - - NOTE: You must complete this Form to ensure proper processing of all medical claims for you and your eligible covered dependents. The form must be completed and returned to the Benefits Department within 2 weeks. To ensure that your claims are handled promptly and efficiently, our Insurance Carrier, BlueCross BlueShield of Central New York, must have up-to-date-information for each individual covered under the Carrols Medical Plan. Please provide the information requested below as it applies to your basic medical coverage, major medical or other health insurance policies. The form must be completed for you and any family member enrolled in the Medical Plan. As you complete the form, please be sure to include any children from a previous marriage who are also covered by the parent s health insurance policy. This form MUST be returned even if no one in your family is covered by another health insurance plan. Please complete the appropriate sections, sign and return it to the Benefits Department using the enclosed postage-paid envelope or fax to 315-410-7357. This form must be received to ensure proper processing of medical claims for you and your eligible covered dependents. 1. Your date of birth: Spouse/other parent date of birth: 2. For those covered under this new medical plan, are you or any members of your family covered under another insurance plan? Yes No If yes, proceed to 3. If no, please sign and return. 3. Name and Address of Other Insurance Co. Policy Number Insured s Name Relation to You 4. Name and Address of Employer Providing Other Health Insurance Name of Those Covered Under the Other Plan 5. Effective date of coverage: 6. Type of OTHER coverage: Hospital Major Medical Medical/Surgical Prescription Drug Vision Dental 7. Does Employee or Spouse have Medicare Part A: Yes No Part B: Yes No I certify that all of the information requested has been completed fully and accurately. Employee signature: Date: Return this completed form to the Employee Benefits Department. The fax number is 315-410-7357. FORM NUMBER: BCBSCOB12
Vision, Dental and/or Dependent Life Dependent Certification Form NOTE: You must complete this form to ensure proper processing of all claims for your eligible dependents ages 19 up to 24. Employee Name: Dependent s Name: EMPLID/POS ID: Dependent s Birth Date Relationship to Employee: Questions 1-5 MUST be completed. 1. Is the dependent married? Yes No If so, Date of Marriage: 2. Is the dependent covered under any other Insurance plan? Yes No If yes, identification number: Policyholder s name: 3. Have you claimed the dependent on your federal income tax return? Yes No 4. Have you provided 50% or more of his/her financial support since your dependent s 19 th birthday? Yes No 5. Please check here if you are required by court order to provide insurance benefits to this dependent. 6. Has the dependent been continuously enrolled as a full-time student since their 19 th birthday? Yes No If no, skip to 12. If yes, complete 7-11. 7. Name and Address of School: 8. Date Enrolled: Student is attending: Full-time Part-time *Please note your signature below authorizes the above named school to verify or release any information needed to confirm full-time attendance at the school. 9. Expected date of graduation from current program: 10. Does the dependent intend to continue in another school immediately after graduation? Yes No 11. Type of diploma student will receive upon graduation: High school College Other (specify) 12. Please indicate date(s) student stopped attending school or was not enrolled as a full-time student: Information provided will be used to determine dependent eligibility/ineligibility. You will be notified if the dependent is determined ineligible as of a date different than provided by you on this form in accordance with the plan. Employee signature: Date: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Please Note: If your dependent s eligibility status changes, you must contact the Benefits Dept. immediately to complete the necessary forms. 10/2013
Life Insurance Beneficiary Form Name: Location: EMPL ID/POS ID #: Date: 1. LIFE INSURANCE BENEFICIARY INFORMATION: Please specify your beneficiary or beneficiaries below and sign and date the bottom of this form. When specifying multiple beneficiaries, you must indicate the percentage of distribution for each. If there is not enough room to specify all beneficiaries, attach, sign and date a separate sheet of paper using the format below. If you are making changes to your existing beneficiary information, this form will replace any previously designated beneficiaries. Please print. BASIC LIFE INSURANCE Beneficiary Name Percentage Social Security # Relationship 1. 2. 3. SUPPLEMENTAL LIFE INSURANCE Beneficiary Name Percentage Social Security # Relationship 1. 2. 3. Beneficiary Authorization---Sign, date & return this completed form to the Benefits Dept. Employee is beneficiary if Dependent Life Insurance is chosen. I designate the above as my beneficiaries in the event of my death. Should I wish to change any beneficiary designations listed above, I further understand that I must complete a new Life Insurance Beneficiary Form. I understand that if I am making changes to existing beneficiary information, this form replaces any previously designated Life Insurance Beneficiary Form I have signed. Employee s Signature: Date: Life Insurance offered by Life Insurance Company of North America, a CIGNA Company Return this completed form to the Employee Benefits Department. The fax number is 315-410-7357. 5 10/2013
Retirement Savings Plan 401(k) CHANGE FORM I. INFORMATION ABOUT YOU PLEASE PRINT Name (First M.I. Last) EMPLID/POS ID Street Address Date of Birth 701635 City State Zip Code Plan ID II. TO CHANGE YOUR EXISTING CONTRIBUTION AMOUNTS Effective immediately, I authorize Carrols Corporation to change my existing weekly salary contribution(s) to the percentage(s) noted below. PRE-TAX basis % of salary to be deferred (1 to 50 % permitted whole percentages only) POST-TAX basis % of salary to be deferred (1 to 50% permitted whole percentages only) I understand the combination of my Pre-tax and Post-tax weekly salary contributions (deferrals) can not exceed 50%. I further understand that my deferrals may be subject to limitations mandated by regulations for the calendar year. Note: Any changes you wish to make to your investment selections must be made through Prudential at www.prudential.com III. BENEFICIARY INFORMATION - complete if you wish to make changes to your existing beneficiaries To make changes to your current Beneficiary information, please use the attached document Beneficiary Designation form. IV. AUTHORIZATION I authorize Carrols Corporation to deduct the above percentage(s) from my weekly compensation, according to the instructions above. Your signature Date Sign this form and immediately return it to the Employee Benefits Department. The Employee Benefits Department Fax is (315) 410-7357. 10/2013
CATCH-UP CONTRIBUTION FORM Carrols Corporation Prudential Retirement Savings Plan Plan ID: 701635 Information About You Name (First M.I. Last) Other Forms May Be Required: Beneficiary Designation Social Security Number Street Address Date of Birth City State Zip Code Phone Number Do You Want to Make a Catch-Up Contribution? Criteria: You must be 50 years or older within the calendar year to be eligible to contribute a Catch-Up Contribution. Yes. I want to make a Catch-Up Contribution (2014 limit $5,500.00) I want to contribute % (increments of 1%) or $ (whole dollar amount) per pay period as a Catch-Up Contribution. No. I do not want to make a Catch-Up Contribution. Investment of Future Contributions Please Note: Your Catch-Up Contributions will be invested using the current investment elections Prudential Retirement has on file for your standard Pre-tax deductions. Approval I certify that the information above is accurate and complete. If I have chosen to contribute to the Plan, I give my employer permission to contribute a portion of my salary to the Plan according to the instructions above. Your Signature: Date: For Employer Use Only Company Authorization: Date: 10/2013
Medical, Dental, Vision, Dependent Life Insurance and Wage Continuation Weekly Deduction Rates January 1, 2014 through December 31, 2014 BCBS PPO Medical Plan 1 Employee Only $38.66 Employee + one dependent $79.31 Employee + two or more dependents $119.94 BCBS PPO Medical Plan 2 Employee Only $38.00 Employee + one dependent $77.95 Employee + two or more dependents $117.88 BCBS PPO Medical Plan 3 Employee Only $33.12 Employee + one dependent $67.95 Employee + two or more dependents $102.76 EBS Dental Employee Only $6.53 Employee + one dependent $13.90 Employee + two or more dependents $20.43 Vision Employee Only $2.01 Employee + one dependent $2.89 Employee + two or more dependents $5.18 Life Insurance Supplemental Dependent Wage Continuation Short Term Disability $.18 per $1,000 coverage Option 1: $.46 per week Option 2: $.59 per week Option 3: $ 1.18 per week $.45 per $10 coverage PRE-TAX DEDUCTIONS Your employee contributions will be taken with pre-tax dollars unless you enroll in post-tax deductions on your Employee Benefits Enrollment Form. Having your deductions taken pre-tax means that the medical, dental, vision and supplemental life insurance premiums will be deducted before Federal, State, and Social Security taxes are computed in your pay. This results in lower tax withholding and higher take home pay. Below is an example of an employee earning $25,000 a year with medical, dental, vision, and supplemental life insurance deductions taken out pre-tax: Earnings $25,000 Pre-tax Deductions - 1,200 Taxable Income $23,800 If the above employee waived the pre-tax election, the entire income of $25,000 would be considered taxable income. NOTE: The before-tax election may mean slightly reduced income tax credits or Social Security benefits at retirement. 10/2013