2018 Benefits Enrollment Form

Transcription

1 2018 Benefits Enrollment Form Need assistance in completing this form? Call the SWN Benefits Center Helpline Complete and submit this form and required documentation to or Section 1: Information Last Name First Name Home Street Address Section 2: Dependent Information & Benefit Coverage: New Dependents & Dependent Changes A dependent is defined as: Your legal spouse, dependent children up to age 26, or a dependent through legal guardianship up to age 26. This section should be used for dependent changes: include dependents that should be added to or removed from your benefit elections. This section continues on page 2.

2 Section 2: Dependent Information & Benefit Coverage: New Dependents & Dependent Changes A dependent is defined as: Your legal spouse, dependent children up to age 26, or a dependent through legal guardianship up to age 26. This section should be used for dependent changes: include dependents that should be added to or removed from your benefit elections. Need to add more dependents? An additional dependent section is available at the end of this form.

3 Section 3: Life Event / Status Change Event Select the applicable status change/life event below. Make note of the enrollment period, required documentation and when your new benefits and/or benefit changes will become effective. In the provided fields below, please indicate the date that the event occurred and when your new benefits/benefits changes will be effective. Event Date: / /2018 Benefits Effective Date: / /2018 Life Event / Status Change Type Enrollment Period & Documentation Deadline Documentation Required Benefits Effective 2018 Annual Enrollment November 13, 2017 Legal Documentation January 1, 2018 New Hire 30 days from date of hire Legal Documentation First of the month on or following your date of hire Marriage 30 days from date of marriage Marriage license Divorce 30 days from date of divorce Divorce decree Birth 60 days from date of birth Birth certificate Date of birth Adoption 60 days from date of adoption Adoption certificate Date of birth or first of the month following the Gain of Other Coverage 30 days from gain of coverage Proof of gain Loss of Other Coverage 30 days from loss of coverage Proof of loss Part to Full Time Employment 30 days from employment change None required Return from Military Leave 30 days from date of return None required Section 4: Medical, Dental & Vision Elections If you choose to make changes to your elections, select the appropriate coverage level and whether or not you wish to add all your existing dependents under your elected coverage. If no selections are made for a benefit, i t w ill b e a ssumed t hat y ou d o n ot w ant t o m ake changes/new elections. You have the option of 2 medical plans. SWN s traditional PPO and the SWN High Deductible Health Plan (HDHP). The PPO has a $500 individual and $1,500 family in-network deductible. The HDHP has a $2,000 individual and a $4,000 family in-network deductible. PPO Medical Plan Monthly Cost Bi-Weekly Cost PPO Plan Election United Healthcare Choice Plus PPO Non-exempt and Bonus target below 10 & Spouse & Child(ren) $ $ $ $ $ $ $ $ & Spouse & Child(ren) United Healthcare Choice Plus PPO Bonus targets 10 through 30 & Spouse & Child(ren) $ $ $ $ $ $ $ $ United Healthcare Choice Plus PPO Bonus targets 35 and above & Spouse & Child(ren) $ $ $ $ $ $ $ $

4 HDHP Medical Plan Monthly Cost Bi-Weekly Cost HDHP Plan Election United Healthcare High Deductible Health Plan Non-exempt and Bonus target below 10 & Spouse & Child(ren) $ $ $ $ $ $ $ $ & Spouse & Child(ren) United Healthcare High Deductible Health Plan Bonus targets 10 through 30 & Spouse & Child(ren) $ $ $ $ $ $ $ $ United Healthcare High Deductible Health Plan Bonus targets 35 and above & Spouse & Child(ren) $ $ $ $ $ $ $ $ Health Savings Account (HSA) Elections For those who elect the HDHP, you can elect to defer pre-tax dollars into a HSA. s can defer up to $3,450 for employee only and up to $6,900 for all other enrollment categories. An additional catch-up is available for employees 55 years of age or older. Payments into your HSA are prorated by the number of pay periods left in the plan year. SWN annually contributes $1,000 for individuals or $2,000 for all other coverage levels to your pre-tax HSA. There is no limit on the balance and the account is portable. Health Savings Account (HSA) Health Savings Account Decline Health Savings Account Select Annual Coverage Amount Dental Plan Option Select Monthly Cost Bi-Weekly Cost Delta Dental Premier & Spouse & Child(ren) $ 4.27 $ 8.55 $ 9.82 $ $ 1.97 $ 3.95 $ 4.53 $ 8.52 Vision Plan Option Select Monthly Cost Bi-Weekly Cost Superior Vision & Spouse & Child(ren) $ 5.63 $ $ $ $ 2.60 $ 5.14 $ 5.04 $ 7.67

5 Section 5: Flexible Spending Account Elections You can elect up to $2,650 for Health Care FSA and up to $5,000 for Dependent Care FSA. To enroll, write down the annual amount you would like to set aside. Deductions for these plans are spread over the course of the year by pay period. For those who enroll in the HDHP AND the HSA, you can enroll in the Limited Purpose Health Care FSA. The funds in this account can be used to cover dental and vision expenses, but not medical. Flexible Spending Account (FSA) Option Select Annual Coverage Health Care FSA Plan Enroll - Full Purpose Enroll - Limited Purpose (HSA only) Dependent Care FSA Plan Enroll Section 6: Life Elections For life benefit coverage below, make changes to or newly elect life coverage. If no selections are made for a benefit, it will be assumed that you do not want to make changes/new elections for this benefit. Basic Life and AD&D and Basic Dependent Life coverage are 100 employer paid. Life Insurance Option Select Basic Life and AD&D $50,000 2x Annual Base Salary Life Insurance Dependent Life Option $5,000 for Spouse / $2,000 per Child Select When you enroll in Basic Life / AD&D coverage yourself, you will also have the option to select Basic Dependent Life for your spouse and children. Voluntary Life If you would like to elect coverage in addition to the Basic Life/AD&D provided by SWN, you have the option to enroll in SWN s Voluntary Group Life (VGL) plan. When enrolling in VGL coverage for yourself, you will also have the option to select coverage for your spouse and/or dependents. If you make a new election for yourself and/or spouse, and evidence of insurability questionnaire must be submitted and approved before the new coverage amounts are confirmed. The maximum VGL coverage for the employee is the lesser of 5 times your annual salary or $500,000. Coverage is elected in increments of $10,000. Life Insurance Select Coverage Amount Voluntary Group Life and AD&D Voluntary Group Life and AD&D Spouse Voluntary Group Life and AD&D Child ID Watchdog By enrolling in MetLife Defender, I understand that I will be contacted directly by ID Watchdog via to register for this Service. I understand that registration will require me to provide personal information in a secure (encryption protected) online environment in order to receive comprehensive protection services from ID Watchdog. Plan Option Select Monthly Cost ID Watchdog Identity Theft Protection & Spouse & Child(ren) Company Paid $ 8.00 $ 8.00 $ 8.00

6 Critical Illness Option Select $10,000 Plan* Select $20,000 Plan* The Critical Illness Plan, offered through Allstate Benefits, provides a lump sum payment upon diagnosis of a covered illness, which includes: Heart Attack, Stroke, Internal Cancer, End Stage Renal Failure, Organ Transplant and Carcinoma in situ/bypass Surgery. You can select coverage from $10,000 to $20,000 for yoursel and 50 of your selected coverage for your dependents. & Spouse & Child(ren) $ 5.37 $ 8.38 $ 5.37 $ 8.38 $ $ $ $ *Rates shown are bi-weekly Off Job Accident Plan Option Select Bi-Weekly Cost Offered through Allstate Benefits, helps to offset the financial burden of out-of-pocket medical expenses in the event of an accident. The benefit pays cash directly to you. & Spouse & Child(ren) $ 6.17 $ $ $ Hospital Indemnity Insurance Option Select Bi-Weekly Cost Hospital visits can be costly, even with the coverage of the SWN medical plans. Hospital Indemnity Insurance, offered through Allstate Benefits, assists with expenses due to hospitalization from accident or illness. & Spouse & Child(ren) $ 5.10 $ $ 8.82 $ 14.16

7 Section 7: Life Beneficiaries New beneficiary designations or beneficiary changes should be indicated here. Include your beneficiary designation type (Contingent or Primary) and percentage (percentage must total 100) for the Basic Life and AD&D plan as well as the Voluntary Group Life and AD&D plan, if elected. Your beneficiaries will be the designated individuals to receive benefits from these life insurance plans. Continued on page 6. Beneficiary Change: Parent: Friend: Member: Grandchild: Beneficiary Designation Beneficiary Designation Beneficiary Change: Parent: Friend: Member: Grandchild: Beneficiary Designation Beneficiary Designation Beneficiary Change: Parent: Friend: Member: Grandchild: Beneficiary Designation Beneficiary Designation

8 Beneficiary Change: Parent: Friend: Member: Grandchild: Beneficiary Designation Beneficiary Designation Section 8: Authorization & Signature I authorize Southwestern Energy Company to deduct from my compensation any and all required contributions or costs for my elected benefit coverages. I acknowledge that by electing these coverages I am authorizing deductions with respect to these benefits that will remain in effect at least until the next annual enrollment period or until I am able to make a change to my benefits as a result of a qualifying life event (status change). Signature Date Additional Section Section 2: Dependent Information & Benefit Coverage - New Dependents & Dependent Changes

9 Additional Section Section 2: Dependent Information & Benefit Coverage - New Dependents & Dependent Changes Beneficiary Change: Parent: Friend: Member: Grandchild: Beneficiary Designation Beneficiary Designation Beneficiary Change: Parent: Friend: Member: Grandchild: Beneficiary Designation Beneficiary Designation

10 AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA ENROLLMENT FORM Remarks: c New Certificate c Change/Increase Certificate # This box for AHL Home Office use only s Name (Last, First, M.I.) Residence Address GENERAL INFORMATION c M c F Social Security Number Zip Phone Number Employer/Association/Union Southwestern Energy Company Primary Beneficiary s Full Name Date Hired Occupation Plant Or Division Relationship Phone Number Contingent Beneficiary s Full Name Relationship Phone Number Last Name COMPLETE THIS SECTION FOR PERSONS TO BE INSURED First Name Relationship Sex Social Security Number Spouse Are you applying for coverage or changing existing coverage due to a qualifying event? Accident c Yes c No Critical Illness c Yes c No Indemnity Medical If Yes, check the qualifying event: c Marriage c Divorce c Birth/Adoption c Spouse/Dependent Child Death c Eligible/Ineligible Child c Spouse New Job/Job Loss c Newly Eligible c Termination c Death Date of Qualifying Event Current Certificate Number(s) c Yes c No Do you currently have any of the following Individual coverages with American Heritage Life Insurance Company (AHL)? Accident c Yes c No Critical Illness c Yes c No Hospital Indemnity c Yes c No If you answered Yes to any of the coverages, please enter the Policy Number Do you wish to terminate this coverage? c Yes c No If Yes, please enter effective date of termination Premium/Billing Mode Bi-Weekly Date of First Deduction Coverage Effective Date 01/01/18 Account Number ID Situs TX (EF L70PA) ABJ4580TX5 Page 1 of 2

11 Accident (GVAP6) Off the Job Accident c Yes c No Base Units Accident Treatment & Urgent Care Rider Units 2 Emergency Room Services Rider Units Outpatient Physician s Rider Units 2 2 ENROLLMENT FORM SELECTION OF COVERAGE (Answer Yes or No and complete for each coverage selected) c Only c +Spouse c +Child(ren) c 3 Section 125 c Yes No $ Total Mode Premium Home Office Use Only Dislocation/Fracture Rider Units Benefit Enhancement Rider Units Accidental Death, Dismemberment and Functional Loss Rider Units For AHL Home Office use only Group No. Account Location Dep Code Smoker Issue Effective Date E S C F EE Y or N SP Y or N Critical Illness (GCIP3) c Yes c No (New Generation) c Plan 1 Basic Benefit Amount $10,000 If covered, Basic Benefit Amount for spouse or other dependents is 50 of the employee s. c Only c +Spouse c +Child(ren) c Home Office Use Only c Plan 2 Basic Benefit Amount $20,000 If covered, Basic Benefit Amount for spouse or other dependents is 50 of the employee s. Indemnity Medical II (GIM2) (New Generation) c Yes c No c Only c +Spouse c +Child(ren) c Section 125 c Yes No $ Total Mode Premium Home Office Use Only ACCEPTANCE/AUTHORIZATION: I hereby request all coverage(s) checked yes above for which I am or may become eligible under the group coverages issued by AHL. I AUTHORIZE my employer to deduct from my salary or wages, if applicable, the necessary premium for the coverages requested. EFFECTIVE DATE: I understand that the effective date of my elected coverages will be the effective date recorded on my Certificate, not the date this Enrollment form is signed. WAIVER/DECLINATION: I understand that if I refuse any coverage for which I am eligible (by checking no above), satisfactory proof of insurability may be required, at my own expense, should I desire to apply for it at a later date. Any such application may be declined on the basis of such proof. Date Signed s Signature Producer s ment. I certify that to the best of my knowledge and belief the information on this form is complete, accurate and correctly recorded. Signature of Soliciting Producer Print Soliciting Producer Name Walter Sprang To be completed by home office or producer, prior to issue: Producer Name Producer Number Servicing Producer: Gallagher Benefit Services Soliciting Producer: Gallagher Voluntary Benefits (EF L70PA) ABJ4580TX5 Page 2 of 2 8RKH0 4RCT0 National Producer Number (NPN) Percentage Credit 50 50