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1 OPEN ENROLLMENT Region One Education Service Center What's New for Easy Enroll SCAN: Enrollment has just become easier! Avoid typing long URLs and scan directly to your benefits websites, videos, and benefits guides. Try it yourself! Scan the following code in the picture. TRY ME BENEFIT UPDATES Medical Dental Accident and more!

2 INTRO Login and complete your benefit enrollment. Open enrollment is from 7/21/16 to 8/22/16. Medical enroll is passive. If you wish to make changes please complete the TRS Enrollment, Change and Declination Form and submit to Hortencia I. Olivarez by no later than 8/22/16. Supplemental benefits enrollment is mandatory. Supplemental benefits are Accident, Critical Illness, Dental, Disability, FSA, Heart Stroke, ID Theft, Legalease and Vision. ENROLLMENT DATES: 07/21/16-08/21/16 CALL CENTER #: (800) LOGIN INSTRUCTIONS OR SCAN 1 Go to: GO 2 Click Login LOGIN 3 Enter Username & Password All login credentials have been RESET to the following defaults: Username: The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. If you have six (6) or less characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. Default Password: Last Name* (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number. Supplemental Benefit elections will become effective 9/1/2016. After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 31 days of event).

3 BENEFIT UPDATES Accident Supplemental Benefits by American Public Life Coverage pays benefit amounts for covered medical expenses as a result of an accident. Benefits are paid in addition to what your medical carrier pays and the money comes to you, not your medical provider. Basic Life, Voluntary Life and AD&D Insurance by ONE AMERICA Base Life Plan: Region One provides a $25,000 Basic Life with AD&D policy at no cost to the employee. Voluntary Term Life: Optional term life is available for the employee up to $500,000 not to exceed 7 times salary, for spouse up to 100% of the employee amount not to exceed $100,000, and unmarried dependent children to age 26 up to $10,000. Age Reduction applies. Guarantee issue: employee $100,000, spouse $25,000 and child(ren) $10,000. Please see brochure for details. AD&D: Accidental Death & Dismemberment pays you or your beneficiary in the event of a dismemberment or death due to an accident. Employee will be covered for 100% of the elected amount, spouse will be covered for 50% of employee elected amount and child(ren) are covered for 10% of employee elected amount. Age Reduction applies. Please see brochure for details. Cancer Insurance by American Fidelity Assurance Company Cancer insurance is designed to be a supplement and pays for many costs not covered by your medical insurance. There are 2 plan options. Both plans include a diagnostic and prevention screening once per calendar year. All new or increases in coverage are subject to pre-existing conditions. Critical Illness by Aflac Critical Illness plan provides you with a lump sum cash benefit in the event of a critical illness such as Heart Attack, Stroke, End- Stage Renal Failure. See brochure for list of illnesses. NEW Dental Insurance by United HealthCare The United HealthCare Dental Plan is a PPO Plan that allows participants the freedom to choose any dentist. Diagnostic and Preventitive Services are paid at 100%, Basic Services are paid at 80% and Major Services are paid at 50%. Orthodontics covered only for children to age 19, with a $1,000 lifetime maximum. Deductibles are $50 per person, $150 per family. Disability Insurance by The Standard Plan provides a monthly income to an individual that is disabled due to an accident or illness. There are 4 different plans available Caller Center Informa on Number: (800) Hours: Monday - Friday, 7:30 A.M - 5:00 P.M with benefits becoming available after the 3rd day of disability, or as late as the 90th day. Benefits are payable to age 65 if disability occurs prior to age 65, and for up to one year at a time if disability occurs after age 65, up to age 70. All new or increases in coverage are subject to pre-existing condition exclusions. NEW Healthcare & Dependent Care FSA by National Benefits Services Tax-sheltered flexible spending accounts allow an individual to set aside dollars to pay for future health care and dependent care expenses. Eligible expenses must be incurred within the plan year. The healthcare reimbursement maximum is $2,550/plan year. The dependent care reimbursement maximum is $5,000 if married or 2,500 if single per plan year. It s Important to Save Your Receipts! The IRS requires the Flex Card be used for eligible expenses only. Most of the time we can verify the eligibility of the expense automatically. Yet, there are instances when you ll receive a letter asking you to furnish an itemized receipt to verify the expense. Heart Stroke Insurance by Bay Bridge Administrators Heart Stroke plan is designed to supplement medical coverage in the event of a Heart Attack, Heart Disease or Stroke. Pre-Existing conditions apply. Please see brochure for details. Identity Theft and LegalGuard by LEGALEASE ID Monitoring offers consumers a comprehensive and proactive defense against identity theft. LegalGuard helps you find the right type of attorney when a need arises. LegalGuard has the experience and relationships with their network providers to match you to the type of attorney you need in the right location, with availability to set up a consultation. make things less stressful. Medical Insurance by TRS ActiveCare Aetna and Allegian Health Plan Medical is a passive enrollment for plan year. TRS ActiveCare Medical Plan Options for are ActiveCare 1-HD, ActiveCare Select, ActiveCare 2 and Allegian Health Plans. Please see plan detail at NEW Vision Insurance by United HealthCare United HealthCare is offering two Vision Plans. Both plans have exam co-pays. High option has not materials copay where as low plan has a $25 co-pay. See brochure for full details.

4 ELIGIBILTY: Enrollment, Change and Declination Form Are you an active employee and making monthly contributions to TRS? Yes If no, are you regularly scheduled to work 10 or more hours per week? Yes SECTION 1: ENROLLMENT/CHANGE TRANSACTION TYPE Annual Enrollment New Employee Add Dependent Special Enrollment No No (If no to both, you are not eligible for TRS ActiveCare coverage) - For District Use Only For New Employee (check one): Effective on Actively at Work Effective 1 st TRS District # day of month following Actively at Work Date: Special Enrollment Event Date: / / Change Only: Name Address Plan/Coverage Decline Coverage: Yes (Complete Section 6) N/A Effective Date of Change/Cancel / / Marriage Court Order Birth/Adoption Loss of Coverage Other: Cancel Employee Death Loss of Eligibility Retirement/Terminated Non-Payment Other: Cancel Dependent Divorce Death Loss of Eligibility Dropped Coverage Other: Effective/Change Date: Employer Approval: Were you covered by another district? Yes No If so, which: SECTION 2: EMPLOYEE INFORMATION Last Name: First Name: MI: Social Security #: Mailing Address: City: State: Zip: Residence Address: City: State: Zip: Home Phone Number: Cell Phone Number: Date of Birth: Sex: M F Language: English Spanish Ethnicity: Do you have a disability affecting your ability to communicate or read? Yes (Please complete Section 8) No Is the Employee Covered By Other Insurance? Yes Carrier/Plan: No Is the Employee Covered by Medicare? Yes Part A Part B Part C Part D Effective: No Reason for Medicare Coverage: Entitlement Age Disability End Stage Renal Disease (ESRD) SECTION 3: COVERAGE SELECTION (Please select a Plan of Coverage Plan or HMO - and Coverage Type) Plan Selection: ActiveCare 1-HD ActiveCare Select ActiveCare 2 HMO Selection: FirstCare Health Plans Scott & White Health Plan Allegian Health Plans (formerly Valley Baptist Health Plans) Coverage Type Selected: Employee Only Employee + Spouse Employee + Child(ren) Employee + Family SECTION 4: DEPENDENT INFORMATION (Use additional form for additional dependents) SPOUSE Last Name: First Name: MI: City: State: Zip: Phone Number: Sex: M F Date of Birth: Social Security #: Natural/Adopted Stepchild Foster Child Grandchild Legal Guardian Disabled Other Phone Number: Natural/Adopted Stepchild Foster Child Grandchild Legal Guardian Disabled Other Phone PLEASE CONTINUE ON NEXT PAGE

5 Natural/Adopted Stepchild Foster Child Grandchild Legal Guardian Disabled Other Natural/Adopted Stepchild Foster Child Grandchild Legal Guardian Disabled Other : SECTION 5: DISABLED DEPENDENTS OVER AGE 26 Request for Continuation of Coverage for Handicapped Child form and Attending Physician s Statement Please note that a Request for Continuation of Coverage for Handicapped Child form and Attending Physician s Statement are required for coverage of a disabled child over age 26. See your Benefits Administrator for the forms, which must be completed in full and submitted to your Benefits Administrator. SECTION 6: DECLINATION OF COVERAGE This is to certify that the available coverage has been explained to me. I have been given the opportunity to apply for the coverage available to me and my dependents and have voluntarily elected to decline the coverage as elected below. Name: SSN: Employee Reason: Other Coverage Other: Name: SSN: Spouse Reason: Other Coverage Other: SECTION 7: COVERAGE CONDITIONS I am employed by the Employer named in this Enrollment Application and Change Form. I am eligible to participate in the coverage(s) offered by the TRS-ActiveCare program which is administered by Aetna, with HMO benefits provided by SHA, L.L.C. dba FirstCare Health Plan, Scott and White Health Plan, and Allegian Insurance Company dba Allegian Health Plans. On behalf of myself and any dependents listed on their Enrollment Application and Change Form, I apply for those coverage(s) for which I am eligible. o If I am enrolling a grandchild in Section 4, I certify that my household is the grandchild s primary residence and the grandchild is my dependent for federal income tax purposes for the reporting year in which coverage of the grandchild is in effect. o If I am enrolling a child as an other Child in Section 4, I certify that my household is the child s primary residence, that I provide at least 50% of the child support, that neither of the children s natural parents reside in my household, and that I have the legal right to make decisions regarding the child s medical care. Only those coverage(s) and amount for which I am eligible will be available to me. I understand that if this Enrollment Application and Change Form is accepted, the coverage(s) will become effective in accordance with the provisions or the TRS-ActiveCare program. I understand that by enrolling for coverage with Employer named in the Enrollment Application and Change Form that any TRS-ActiveCare coverage I previously elected under another TRS-ActiveCare participating district/entity will be terminated under TRS Rules. I authorize necessary payroll deduction by my Employer, if any, to cover the cost of my coverage(s). I agree that my Employer acts as my agent. All notices given to my Employer are binding upon me. I also agree that my participation in the coverage(s) is subject to any future amendments. I understand that by declining TRS-ActiveCare coverage now or by terminating TRS-ActiveCare coverage during the plan year, I am not eligible to re-enroll in TRS-ActiveCare until the next plan year, unless I experience a special enrollment event. I state that the information given on the Enrollment Application and Change Form is true and correct. I understand and agree that any incorrect statements material to the risk and knowingly made by me will invalidate my coverage(s). Applicant Signature: Date: SECTION 8: SPECIAL NOTES REGARDING MY ENROLLMENT (Please indicate any special information regarding my enrollment for Aetna, Caremark or my selected HMO)