2016 Benefits Enrollment Form

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Gertrude Tucker
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2016 Benefits Enrollment Form Need assistance in completing this form? Call the SWN Benefits Center Helpline 855.796.

Section 1: Information Last Name First Name Home Street Address Section 2: Dependent Information & Benefit Coverage: New Dependents & Dependent Changes A dependent is

1 2016 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: includes 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: includes 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 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: / /2016 Benefits Effective Date: / /2016 Life Event / Status Change Type Enrollment Period & Documentation Deadline Documentation Required Benefits Effective 2016 Annual Enrollment November 13, 2015 None required January 1, 2016 New Hire 30 days from date of hire None required 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, it will be assumed that you do not want to make 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 $250 individual and $750 family deductible. The HDHP has a $1,500 individual and a $3,000 family or all other categories deductible. PPO Medical Plan Option Monthly Cost Bi-Weekly Cost United Healthcare Choice Plus PPO Non-exempt and Bonus target below 10 & 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 Option Monthly Cost Bi-Weekly Cost United Healthcare High Deductible Health Plan Non-exempt and Bonus target below 10 & Spouse & Child(ren) $ $ $ $ $ $ $ $ United Healthcare High Deductible Health Plan Non-exempt and Bonus target below 10 & Spouse & Child(ren) $ $ $ $ $ $ $ $ United Healthcare High Deductible Health Plan Non-exempt and Bonus target below 10 & 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 $3,350 for employee only and up to $6,750 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. These funds can only be used for medical expenses. SWN annually contributes $600 for individuals or $1,200 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 Annual Coverage Amount Dental Plan Option Monthly Cost Bi-Weekly Cost Delta Dental Premier & Spouse & Child(ren) $ 4.00 $ 8.01 $ 9.20 $ $ 1.85 $ 3.70 $ 4.25 $ 7.99 Vision Plan Option Monthly Cost Bi-Weekly Cost Superior Vision & Spouse & Child(ren) $ 5.80 $ $ $ $ 2.68 $ 5.30 $ 5.20 $ 7.90

5 Section 5: Flexible Spending Account Elections You can elect up to $2,550 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 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 Basic Life and AD&D - $50,000 2x Annual Base Salary Life Insurance Dependent Life Option $5,000 for Spouse / $2,000 per Child 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 Coverage Amount Voluntary Group Life and AD&D Voluntary Group Life and AD&D Spouse Voluntary Group Life and AD&D Child MetLife Defender By enrolling in MetLife Defender, I understand that I will be contacted directly by MetLife Defender 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 MetLife Defender. Plan Option Monthly Cost MetLife Defender Identity Theft Protection & Spouse & Child(ren) Company Paid $ 8.00 $ $ 16.00

6 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. Parent: Friend: Member: Grandchild: Beneficiary Designation Beneficiary Designation Parent: Friend: Member: Grandchild: Beneficiary Designation Beneficiary Designation Parent: Friend: Member: Grandchild: Beneficiary Designation Beneficiary Designation

7 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

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

2018 Benefits Enrollment Form

2018 Benefits Enrollment Form Need assistance in completing this form? Call the SWN Benefits Center Helpline 855.796.3637 Complete and submit this form and required documentation to houston.gbs.bac.tasks@ajg.com