2015 BENEFITS ENROLLMENT FORM

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Delphia Little
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1 Page 1 of 5 Please complete this form and return (with required, supporting documentation) via fax to or scan the form and required, supporting documentation and to benefits@uchicago.edu. This form and all required, supporting documentation must be received within 31 days of your Hire Date. Employee Information Name: Last Name, First Name, Middle Initial (Please Print and use BLACK INK ONLY) Gender Male Female SS # Date of Birth Hire Date Address City, State, Zip Home Phone Work Phone Work Select Medical Plan I want to be covered by the following Medical Plan: (Check one box) Maroon Plan (BCBS IL PPO) New Hire Effective Date: Maroon Savings Choice Plan (BCBS IL PPO) with a Health Savings Account University of Chicago Health Plan (UCHP) Illinois Platinum HMO (Humana) HMO Illinois (BCBS IL HMO) I want to waive Medical Coverage (I certify that I currently have other Medical Coverage). Select the level of Coverage you want below: (Check one box) Select Dental Plan I want to be covered by the following Dental Plan: (Check one box) MetLife Dental Co-Pay Plan I want to waive dental coverage. Select the level of Coverage you want below: (Check one box) MetLife Dental PPO Plan Select Vision Coverage I want to select the following level of VSP Coverage: (Check one box) I want to waive vision coverage.

2 Page 2 of 5 Group Life Insurance The University provides benefits eligible employees with a Basic Life Insurance benefit of up to $50,000 as well as an opportunity to purchase additional life insurance. The University also provides life insurance protection for your spouse, same-gender domestic partner (who is registered with the University of Chicago), civil union partner or children (under age 26). Supplemental Life You may elect additional life insurance for yourself equal to a multiple of your annual salary (1x, 2x, 3, 4x, 5x, 6x, 7x, or 8x); to an overall maximum of $1,500,000 (basic and supplemental life combined). During the first 31 days following your hire or benefits eligible date, Evidence of Insurability is not required for coverage up to $750,000. After the first 31 days following your hire or benefits eligible date, Evidence of Insurability is required for all coverage amounts. You must complete the Evidence of Insurability process and your coverage election will become effective on the Insurance Company s approval date. I elect x my annual salary. Dependent Life I do not wish to elect Supplemental Life. You may elect life insurance for your Spouse, Same-Gender Domestic Partner (who is registered with the University of Chicago) or Civil Union Partner in $10,000 increments up to $150,000. During the first 31 days following your hire or benefits eligible date, Evidence of Insurability is not required for coverage up to $20,000. After the first 31 days following your hire or benefits eligible date, Evidence of Insurability is required for all coverage amounts. The Evidence of Insurability process must be completed and coverage will become effective on the Insurance Company s approval date. I elect $ worth of life insurance coverage for my spouse/partner. You may elect life insurance for your child(ren) up to age 26 in $2,000 increments up to $10,000. Evidence of Insurability is not required for any coverage amounts. You may cover one child or multiple children in your family. Your will only pay premiums on one level of coverage. I do not wish to elect life insurance for my spouse/partner. I elect $ worth of life insurance coverage for my child(ren). I do not wish to elect life insurance for child(ren). Long Term Disability The University offers benefits-eligible employees long-term disability insurance, which provides supplemental income when you are unable to work for more than three months. You can choose between the Base and Optional Plan and must be actively at work on the date coverage begins. During the first 31 days following your hire date, Evidence of Insurability is not required for participation in either plan. After the first 31 days following your hire date, Evidence of Insurability is required for participation in the Optional Plan. You must complete the Evidence of Insurability process and your coverage election will become effective on the Insurance Company s approval date. I elect to participate in the Base Plan. I am age 65 or older and elect to waive participation. I elect to participate in the Optional Plan. Personal Accident Insurance The University of Chicago offers benefits-eligible employees personal accident insurance, which provides a benefit if you or a covered family member dies or suffers a serious injury in an accident. You may elect in $10,000 increments up $1,000,000 worth of personal accident insurance for you and your dependents to a maximum of 10 times your annual salary. A minimum of $20,000 worth of coverage is required to participate. Evidence of Insurability is not required for any coverage amounts. I elect $ worth of Personal Accident insurance coverage for myself only. I do not wish to elect Personal Accident Insurance. I elect $ worth of Personal Accident insurance coverage for myself and my family.

3 Page 3 of 5 Employee/Dependent Coverage If you enroll in UCHP list the physician or PCG, HMO-IL list the Medical Group Name+ Group I.D. number, Humana list the Physician + I.D. number, each Dependent may select a different contracting Medical Group/Physician. Relationship Employee Name (Last, [if different], First, MI) Date of Birth MM/DD/YY SS # HMO Medical - Group Name & I.D. # or - Physician s Name & I.D.# Medical Vision Dental Dependent Life Personal Accident (Only enter Medical Group/Physician Name & Number if enrolling into a HMO medical plan) Husband Wife Civil Union Partner U of C Registered Domestic Partner Male Female

4 Page 4 of 5 Life/Personal Accident Beneficiaries I designate the following beneficiary(ies) for Life and Personal Accident Insurance Coverage. Contingent beneficiary(ies) will only receive the benefit if the primary beneficiary(ies) are deceased. (If necessary, use an additional page) Name Relationship SS# Designated Percentage (%) Primary Contingent Flexible Spending Account (FSA) You may elect to contribute to a Health Care FSA an annual minimum of $250 and maximum of $2,550, if not enrolled in the Maroon Savings Choice medical plan. You may elect to contribute to a Dependent Care FSA, an annual maximum of $5,000. (Highly Compensated employees can only contribute up to a maximum of $1,900.) I am paid Bi-Weekly. I I am paid Monthly. I elect to contribute an annual amount of $ to a Health Care FSA to pay for health expenses incurred by myself and my dependents. I elect to contribute an annual amount of $ to a Dependent Care FSA to pay for daycare expenses for my dependent child under the age of 13 or an adult relative (disabled spouse, elderly parent), while I am at work. I request a change in status. Please note: Annual amounts elected will be divided equally per pay period in calendar year You have until March 15, 2016 to incur claims, before your election amount is forfeited. Health Care Savings Account (HSA) You may elect to contribute to a Health Care Savings Account, only if enrolled in the Maroon Savings Choice medical plan, an annual maximum of $2,850 (if enrolled as an individual) or $5,650 (if enrolled with a spouse and/or children). I am paid Bi-Weekly. I am paid Monthly. I elect to contribute an annual amount of $ to a Health Care Savings Account to pay for health expenses incurred by myself and my dependents. I request a change in status. Please note: Annual amounts will be divided equally per pay period in calendar year Any unused funds will automatically roll over to the next year.

5 Page 5 of 5 Signature/Authorization (sign and date below) By signature below I certify that: I hereby apply for participation in my employer s benefits plan(s) for those benefits for which I am or may become eligible under the terms and conditions of said plan and any present or future amendments thereto, and subject to acceptance of my enrollment. I hereby authorize my employer to deduct from my earnings the required contributions, if any, toward the cost of this plan (s). I understand that I cannot change any of the elections for medical, dental, vision coverage, flexible spending accounts and health savings accounts until the next open enrollment period, unless I have a qualifying life event. Deductions for these plans will be taken on a pre-tax basis. If I waived medical coverage, I certify that I have other medical coverage. I understand the effect of any pre-tax contributions on my pay. I authorize the release to and use by the claims processor of any medical information necessary to establish the validity of any claim for benefits for myself or on behalf of my eligible dependents. This authorization shall remain valid from the date signed through the term of coverage of the program. A copy of this authorization shall be as valid as the original. I certify that I have read the provisions hereof which are hereby incorporated in and made a part of this form. Employee Name (Please Print) Employee Signature Date IMPORTANT INFORMATION Please include all required, supporting documentation (marriage certificate, birth certificates, etc.) with this form and fax to or scan and to benefits@uchicago.edu. Information regarding required, supporting documentation may be accessed at:

(Please Print and use BLACK INK ONLY) Employee Information Name: Last Name, First Name, Middle Initial. Male Female SS # Date of Birth Hire Date

(Please Print and use BLACK INK ONLY) Employee Information Name: Last Name, First Name, Middle Initial. Male Female SS # Date of Birth Hire Date Page 1 of 5 Please complete this form and return (with required, supporting documentation) via fax to 773-753-3319 or scan the form and required, supporting documentation and email to benefits@uchicago.edu.