2019 EMPLOYEE BENEFITS ELECTION FORM

EXPRESS OPEN ENROLLMENT

For subscribers who are currently enrolled (along with all your eligible dependents) in the Medical, Dental, and Vision benefits and are making no changes.

Employee Information

First Name

MI

Last Name

Email Address

Voluntary Term Life Benefit

Do you want to increase your life insurance protection through the Principal Voluntary Term Life Benefit?

YES

NO

IF YES, PLEASE INDICATE VOLUNTARY TERM AMOUNT IF YES, PLEASE INDICATE VOLUNTARY TERM AMOUNT

Do you want spousal life insurance protection through the Principal Voluntary Term Life Benefit?

Please Note: Spousal coverage is available only if opting for employee coverage. Spousal coverage cannot be more than employee coverage.

YES

NO

IF YES, PLEASE INDICATE SPOUSAL VOLUNTARY TERM AMOUNT IF YES, PLEASE INDICATE SPOUSAL VOLUNTARY TERM AMOUNT

Voluntary Long Term Disability Benefit

Do you want to participate in the Principal Long Term Disability benefit?

YES

NO

I and all of my eligible dependents are currently enrolled in the Medical, Dental , and Vision benefits, and I elect to make no changes in my coverage status for those benefits for 2019. I agree to have my 2019 contributions to premiums deducted from payroll every 2 weeks on a pre-tax basis.

Signature of Employee

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Date

Congratulations! You are one step away from completing the Express Open Enrollment! Please now submit your form by scrolling down to the bottom of this page and clicking the Submit button.

However, if you want to enroll in the FSA for 2019, please complete and sign the FSA section before submitting. Your 2018 FSA election does not automatically renew for 2019. If you wish to participate in the FSA program for 2019, you must make a new election.

REMINDER: This form is not used for LegalShield enrollment. LegalShield enrollment is processed through Leiters' LegalShield website, which can be accessed through the link in the LegalShield section of the Leiter's 2019 Open Enrollment page.

STANDARD OPEN ENROLLMENT

For participants not eligible for Express Open Enrollment

Employee Information

First Name

MI

Last Name

e-mail address

Date of Full-Time Employment

THE FOLLOWING 2 FIELDS ARE FOR UNITEDHEALTHCARE SILVER 2250 HMO ONLY

Employee's HMO Primary Care Physician (PCP)

Provider ID Number

Search for a PCP and provider ID number here: https://connect.werally.com/plans/uhcWest/17

Select "SignatureValue HMO" → Enter your zip code → Click "Continue"→ Click "Continue" on the next page →Click on "People" box → Click on "Primary Care" box → Click on "Primary Care Physician (PCP)"

Please Elect Coverages

MEDICAL

Please select one:

KAISER $20 CO-PAY HMO

KAISER GOLD 0/30 HMO

KAISER COLORADO PLATINUM 0/20 HMO (Colorado residents only)

UNITEDHEALTHCARE SILVER 2250 HMO

UNITEDHEALTHCARE PLATINUM PPO $250 DEDUCTIBLE

UNITEDHEALTHCARE GOLD PPO $750 DEDUCTIBLE

UNITEDHEALTHCARE SILVER PPO $1,500 DEDUCTIBLE

Please Select for Medical Coverage:

EE ONLY

EE + SPOUSE/DOMESTIC PARTNER

EE + CHILD(REN)

EE + SPOUSE + CHILD(REN)

DENTAL

Please Select for Dental Coverage:

EE ONLY

EE + SPOUSE/DOMESTIC PARTNER

EE + CHILD(REN)

EE + SPOUSE + CHILD(REN)

VISION

Please Select for Vision Coverage:

EE ONLY

EE + SPOUSE/DOMESTIC PARTNER

EE + CHILD(REN)

EE + SPOUSE + CHILD(REN)

VOLUNTARY TERM LIFE INSURANCE BENEFIT

Do you want to increase your life insurance protection through the Principal Voluntary Term Life Benefit?

YES

NO

IF YES, PLEASE INDICATE VOLUNTARY TERM AMOUNT IF YES, PLEASE INDICATE VOLUNTARY TERM AMOUNT

Do you want spousal life insurance protection through the Principal Voluntary Term Life Benefit?

Please Note: Spousal coverage is available only if opting for employee coverage. Spousal coverage cannot be more than employee coverage.

YES

NO

IF YES, PLEASE INDICATE SPOUSAL VOLUNTARY TERM AMOUNT IF YES, PLEASE INDICATE SPOUSAL VOLUNTARY TERM AMOUNT

VOLUNTARY LONG TERM DISABILITY BENEFIT

Do you want to participate in the Principal Long Term Disability benefit?

YES

NO

Please List Dependents To Be Insured Under Any Coverages

SPOUSE/DOMESTIC PARTNER:

First Name

MI

Last Name

Social Security Number

Date of Birth

Gender

Male

Female

THE FOLLOWING 2 FIELDS ARE FOR UNITEDHEALTHCARE SILVER 2250 HMO ONLY

Spouse's HMO Primary Physician Name

Provider Number

DEPENDENT/ADULT CHILD:

1. First Name

MI

Last Name

Social Security Number

Date of Birth

Gender

Male

Female

THE FOLLOWING 2 FIELDS ARE FOR UNITEDHEALTHCARE SILVER 2250 HMO ONLY

Child's HMO Primary Physician Name

Provider Number

2. First Name

MI

Last Name

Social Security Number

Date of Birth

Gender

Male

Female

THE FOLLOWING 2 FIELDS ARE FOR UNITEDHEALTHCARE SILVER 2250 HMO ONLY

Child's HMO Primary Physician Name

Provider Number

3. First Name

MI

Last Name

Social Security Number

Date of Birth

Gender

Male

Female

THE FOLLOWING 2 FIELDS ARE FOR UNITEDHEALTHCARE SILVER 2250 HMO ONLY

Child's HMO Primary Physician Name

Provider Number

4. First Name

MI

Last Name

Social Security Number

Date of Birth

Gender

Male

Female

THE FOLLOWING 2 FIELDS ARE FOR UNITEDHEALTHCARE SILVER 2250 HMO ONLY

Child's HMO Primary Physician Name

Provider Number

5. First Name

MI

Last Name

Social Security Number

Date of Birth

Gender

Male

Female

THE FOLLOWING 2 FIELDS ARE FOR UNITEDHEALTHCARE SILVER 2250 HMO ONLY

Child's HMO Primary Physician Name

Provider Number

Signature

I agree: All information on this form is correct and true to the best of my knowledge and belief. I understand that it is the basis on which coverage may be issued under these plans. I understand that if I have committed fraud or made an intentional misrepresentation of any material fact that within 24 months of issuance, my coverage may be cancelled or, following notice, rescinded. I further authorize my employer to deduct from my earnings the contribution (if any) required toward the cost of these plans.

I understand that coverages do not become effective until the information contained herein has been approved by the carriers.

Signature of Employee

clear

Print Name of Employee

Date

Refusal of Coverage

I am declining coverage as follows:

MEDICAL

Myself

My Spouse

My Child(ren)

DENTAL

Myself

My Spouse

My Child(ren)

VISION

Myself

My Spouse

My Child(ren)

I acknowledge that by declining coverage for myself or an eligible dependent, I will not be able to enroll again until January 2020, or during a special enrollment period if I have experienced a qualifying event. I must request coverage within 31 days of a qualifying event.

Signature of Employee (Please sign ONLY if you are declining any coverages)

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Date

FLEXIBLE SPENDING ACCOUNT (FSA)

Please complete and sign only if enrolling in the FSA plan

Employee Information

First Name

MI

Last Name

Social Security Number

Date of Birth

Gender

Male

Female

Home Address

City

State

Zip Code

Home or Daytime Phone

Email Address

Please select one:

Healthcare FSA

Annual Election Amount (up to $2,700)

Dependent Care

Annual Election Amount (up to $5,000)

Contributions are made on a pro-rata, per payroll basis.

I acknowledge and agree to these IRS required conditions for reimbursement. The IRS regulation states four conditions. 1) Any expenses you incur must be within the plan year; 2) Expenses you incur may not be reimbursed by any other source, such as insurance; 3) You must provide proper documentation to receive payment; 4) You cannot change or revoke your election during the plan year unless there is a specific change of status and your employer allows such a change.

Signature of Employee

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Date

Contact

For any questions or help completing this form please contact our broker, Baxter & Associates, at (408) 249-5678.

REMINDER: This form is not used for LegalShield enrollment. LegalShield enrollment is processed through Leiters' LegalShield website, which can be accessed through the link in the LegalShield section of the Leiters' 2019 Open Enrollment page.