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ReHire  DateIND 258600-TIF OFFICE  USE  ONLYEMPLOYEE  INFORMATION(Must  Be  Filled  Out)- Social  Security  Number/Date  of  BirthENROLLMENT  FORM  -  PLAN  1USE  BLACK  or  BLUE  INK  ONLYSex M FYesNo If  Yes:Medicare  Health  Insurance  Claim  Number  (HICN)NameStateHome  Phone/Medicare  Effective  DateNames  of  Covered  Person(s)Street  AddressCity- /Do  you  or  any  dependents  have  Medicare?- //Zip- /1.2.3.4. RX 0867 HQUROO LQ WKH 0HGLFDO ,QVXUDQFH 3ODQ EHIRUH DGGLQJ DQ\ DGGLWLRQDO EHQHILWV RXU FRYHUDJH OHYHO IRU WKH DGGLWLRQDO EHQHILWV ZLOO EH LGHQWLFDO WR \RXU PHGLFDO SODQ VHOHFWLRQ BENEFIT  SELECTIONWeekly   Rat esMEDICALREQUIRED  DEPENDENT  INFORMATIONName 19.98  Employee   OnlySocial  Security  Number 40.54  Employee   1Date  of  BirthRelationship: 54.14  Employee     FamilyNO  to  all  benefits.If NO is checked, sign and date the bottom of the form andgo no further.DENTALYESNO 5.23  Employee   Only 10.46  Employee   1 17.26  Employee     FamilyVISIONYESNO 2.35  Employee   Only 4.00  Employee   1 5.64  Employee     FamilyTERM  LIFEYESNO 0.60  Employee   Only 0.90  Employee   1 1.80  Employee     Family- /- /Sex M FSpouse         Domestic  Partner           ChildName- Social  Security  NumberDate  of  BirthRelationship:/- /Sex M FSpouse         Domestic  Partner           ChildName- Social  Security  NumberDate  of  BirthRelationship:/- /Sex M FSpouse         Domestic  Partner           ChildName- Social  Security  NumberDate  of  BirthRelationship:/- /Sex M FSpouse         Domestic  Partner           ChildBENEFICIARY  INFORMATIONFor  Term  Life  /  Accidental  Death  &  Dismemberment,  please  writein  your  beneficiary  information.NAME  OF  BENEFICIARYRELATIONSHIPAccidental  Death  &  Dismemberment  is  part  of  the  Term  Life  Benefit.I have read the benefit packet and understand its limitations. I understand that open enrollment is only available for a limitedtime and I understand that making no benefit selection is a declination of coverage.ŹSignatureDate//Form:  ESC  NAY  P1  v11

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FREQUENTLY ASKED QUESTIONSHow do I enroll?(QUROOLQJ LQ WKH (VVHQWLDO 6WDII& 5( SODQ LV HDV\ RX FDQ HQUROO E\ FRPSOHWLQJ DQ (VVHQWLDO 6WDII& 5( HQUROOPHQW DSSOLFDWLRQ DQG UHWXUQLQJ LW WR \RXU PDQDJHU When can I enroll in the plan? V D IXOO WLPH DQG RU SDUW WLPH HPSOR\HH \RX DUH DEOH WR HQUROO LQ WKH (VVHQWLDO 6WDII& 5( SURJUDP ZLWKLQ GD\V RI \RXU KLUH GDWH VW SD\FKHFN GDWH RU \RXU HPSOR\HU·V DQQXDO GD\ RSHQ HQUROOPHQW SHULRG ,I \RX GR QRW HQUROO GXULQJ RQH RI WKHVH WLPH SHULRGV \RX ZLOO KDYH WR ZDLW XQWLO WKH QH[W DQQXDO RSHQ HQUROOPHQW XQOHVV \RX KDYH D TXDOLI\LQJ OLIH HYHQW RX KDYH GD\V IURP WKH GDWH RI WKH TXDOLI\LQJ OLIH HYHQW WR HQUROO What is a qualifying life event?If I complete an enrollment form, but do not get placedon assignment right away, will I have to complete anew form? IWHU VL[ PRQWKV LI WKHUH KDV QRW EHHQ D GHGXFWLRQ IURP \RXU SD\FKHFN SOHDVH À OO RXW D QHZ HQUROOPHQW IRUP 0LVVLQJ LQIRUPDWLRQ ZLOO GHOD\ WKH SURFHVV Can I make changes or cancel coverage? RX PD\ FDQFHO RU UHGXFH FRYHUDJH DW DQ\ WLPH XQOHVV \RXU SUHPLXPV DUH GHGXFWHG SUH WD[ RX ZLOO RQO\ KDYH GD\V IURP \RXU KLUH GDWH RU À UVW SD\FKHFN GDWH WR HQUROO DGG DGGLWLRQDO EHQHÀ WV RU DGG DGGLWLRQDO LQVXUHG PHPEHUV IWHU WKLV WLPH IUDPH \RX ZLOO RQO\ EH DOORZHG WR HQUROO DGG EHQHÀ WV RU DGG DGGLWLRQDO LQVXUHG PHPEHUV GXULQJ \RXU DQQXDO RSHQ HQUROOPHQW SHULRG RU ZLWKLQ GD\V RI D TXDOLI\LQJ OLIH HYHQW TXDOLI\LQJ OLIH HYHQW LV GHÀ QHG DV D FKDQJH LQ \RXU VWDWXV GXH WR RQH RI WKH IROORZLQJ 0DUULDJH RU GLYRUFH %LUWK RU DGRSWLRQ RI D FKLOG UHQ 7HUPLQDWLRQ 'HDWK RI DQ LPPHGLDWH IDPLO\ PHPEHU 0HGLFDUH HQWLWOHPHQW (PSOR\HU EDQNUXSWF\ /RVV RI GHSHQGHQW VWDWXV /RVV RI SULRU FRYHUDJH(Please refer to the “PLEASE NOTE” section on theprevious page to see if you are Post-Tax or Pre-Tax),Q DGGLWLRQ \RX PD\ UHTXHVW D VSHFLDO HQUROOPHQW IRU \RXUVHOI \RXU VSRXVH DQG RU HOLJLEOH GHSHQGHQWV ZLWKLQ GD\V RI WHUPLQDWLRQ RI FRYHUDJH XQGHU 0HGLFDLG RU D 6WDWH &KLOGUHQ·V HDOWK ,QVXUDQFH 3URJUDP 6& ,3 RU XSRQ EHFRPLQJ HOLJLEOH IRU 6& ,3 SUHPLXP DVVLVWDQFH XQGHU WKLV PHGLFDO EHQHÀ W 5HPHPEHU LW PD\ WDNH XS WR WZR RU WKUHH ZHHNV IRU WKH FKDQJHV RU FDQFHOODWLRQ WR EH UHÁ HFWHG RQ \RXU SD\FKHFN &RYHUDJH ZLOO FRQWLQXH DV ORQJ DV \RX KDYH D SD\FKHFN GHGXFWLRQ Are dependents covered? HV (OLJLEOH GHSHQGHQWV LQFOXGH \RXU VSRXVH DQG \RXU FKLOGUHQ XS WR DJH 7KHUH DUH QR UHVWULFWLRQV IRU SUH H[LVWLQJ FRQGLWLRQV LQ WKLV PHGLFDO SODQ (YHQ LI \RX ZHUH SUHYLRXVO\ GLDJQRVHG ZLWK D FRQGLWLRQ \RX FDQ UHFHLYH FRYHUDJH IRU UHODWHG VHUYLFHV DV VRRQ DV \RXU FRYHUDJH JRHV LQWR HIIHFW When does coverage begin?Is there coverage for contraceptives on this plan?&RYHUDJH ZLOO EHJLQ WKH 0RQGD\ IROORZLQJ D SD\UROO GHGXFWLRQ DQG FRQWLQXHV DV ORQJ DV \RX KDYH D GHGXFWLRQ IURP \RXU SD\FKHFN 3OHDVH UHYLHZ \RXU FKHFN VWXE IRU GHGXFWLRQV ,I \RX PLVV D SD\UROO GHGXFWLRQ WR DYRLG D EUHDN LQ FRYHUDJH \RX PD\ PDNH GLUHFW SD\PHQWV WR 3 , IWHU VL[ FRQVHFXWLYH ZHHNV ZLWKRXW D SD\UROO GHGXFWLRQ RU GLUHFW SUHPLXP SD\PHQW FRYHUDJH ZLOO EH WHUPLQDWHG DQG &2%5 LQIRUPDWLRQ ZLOO EH VHQW DW WKDW WLPH 2UDO FRQWUDFHSWLYHV DUH FRYHUHG XQGHU WKH SUHVFULSWLRQ EHQHÀ W 1RQ RUDO FRQWUDFHSWLYHV DUH QRW FRYHUHG How can I make changes?7R PDNH FKDQJHV RU FDQFHO FRYHUDJH E\ WHOHSKRQH FDOO (QWHU \RXU 3,1 &2'( SOXV WKH ODVW IRXU GLJLWV RI \RXU 6RFLDO 6HFXULW\ QXPEHU 661 PIN CODE: B B B B 142ODVW IRXU GLJLWV RI \RXU 661,V WKHUH D SUH H[LVWLQJ FODXVH IRU WKH 0HGLFDO %HQHÀ W" UH PDWHUQLW\ EHQHÀ WV FRYHUHG" HV PDWHUQLW\ EHQHÀ WV DUH FRYHUHG WKH VDPH DV DQ\ RWKHU FRQGLWLRQ XQGHU WKLV SODQ

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