NEW EMPLOYEE BENEFIT CHECKLIST

Transcription

1 NEW EMPLOYEE BENEFIT CHECKLIST EMPLOYEE NAME Notice of University GAP Plan Eligibility provided GAP enrollment received State Retirement System (SERS) OR Optional Retirement Program (ORP, if eligibility notice provided) Mandatory Retirement* Date of Birth Fidelity TIAA/CREF VALIC Social Security statement (Form SSA-1945) For HR Use Only: 5% 7% 8% 9% 9% 64% salary cap 2% Member: Prior to 1/1/75 01/01/75-12/31/83 01/01/84-06/30/96 07/01/96-01/01/11 After 01/01/11 After 01/01/79 MA Group Insurance Commission Benefits Health Insurance* ENROLL WAIVE HIRD Circle one: Individual Family Plan: Basic Life Insurance* ENROLL WAIVE Additional Life Insurance* ENROLL WAIVE Multiple of Salary Non-automatic amount Long Term Disability Insurance* ENROLL WAIVE Pre-tax Dependent Care Spending Account (DCAP) ENROLL WAIVE Pre-tax Health Care Spending Account (HCSA) ENROLL WAIVE Employee Acknowledgement Form* Dental Insurance Circle one: Individual Family MSP* USA/MTA* NON-UNIT* PSU/MTA** AFSCME** IBPO** **Enrollment information will be forthcoming from Plan Administrator. Voluntary Sick Leave Enrollments IBPO Sick Leave Bank Police Officers, Unit: A or B ENROLL WAIVE N/A MSP Sick Leave Bank Faculty & Librarians Only ENROLL WAIVE N/A *I understand that my name will not be added to the Division of Human Resources Management Information System until all of the requisite paperwork has been completed and returned to the Human Resources Employee Service Center, room 325, Whitmore Administration Building. I acknowledge that if I am GAP Plan eligible and have not submitted a GAP Plan enrollment form I will be defaulted into a GAP Plan of the University s choosing. Signature Date 41

2 GIC ENROLLMENT/CHANGE FORM (FORM-1) Health, Basic Life, Optional Life, and Long Term Disability Insurance REQUIRED INSURED INFORMATION Insured Information Address Contact Information Employment Information GIC-ID (usually Soc. Sec. #) Sex Date of Birth Dept. ID # or Agency/Division # M F / / / Name Last First MI Street City State Zip Home or Cell Phone ( ) Work Phone ( ) Bargaining Unit/Union Name HR/CMS or UMASS Employee ID # Full-time Part-time Hours/week: Country (if not USA) Date of Hire / / REQUIRED Select all that apply: New Enrollment Annual Enrollment Adding Dependent(s) Address Change Dropping Dependent(s) Name Change Decline GIC Health Insurance Decline All GIC Coverage Qualifying Status Change Marriage Birth/Adoption Divorce/Legal Separation Change in Dependent Eligibility Status Gain of Other Coverage Date of Event: / / Involuntary Loss of Other Coverage Return from FMLA or Military Leave Death of spouse/dependent Spouse s Annual Enrollment Moved out of health plan s service area HEALTH, BASIC LIFE, OPTIONAL LIFE AND LTD Effective Date: / 01 / Health Plan Optional Life Basic Life Only Long Term Disability (LTD) Basic Life and Health (For GIC Coordinator use only) Annual Salary: $ Salary Effective Date: / / Cancel Coverage Long Term Disability (LTD) Health Insurance Optional Life Insurance Fallon Direct (HMO) Health New England (HMO) UniCare State Indemnity/Basic Coverage Fallon Select (HMO) (Closed to New Members) NHP Prime Neighborhood Health Plan (HMO) CIC: Yes No Election Harvard Pilgrim Independence (POS) Tufts Health Plan Navigator (POS) UniCare Community Choice (PPO-type) Individual (Closed to New Members) (Closed to New Members) UniCare/PLUS (PPO-type) Family Harvard Pilgrim Primary Choice (HMO) Tufts Health Plan Spirit (HMO-type) Enrollment/Change: (check one) Automatic Increase select multiple of salary 1x 2x 3x 4x 5x 6x 7x 8x Multiple Factor 2-8 times is allowed only with Automatic Increase. Fixed Amount Amount $ Will not increase as your salary increases. No more than $1,000 less than annual salary rounded down to the nearest $1,000. SPOUSE/DEPENDENT INFORMATION (See instructions on back) Family Status Change: (Check one and complete Qualifying Status Change box above) Automatic Increase select multiple of salary 1x 2x 3x 4x Fixed Amount Amount $ Will not increase as your salary increases. No more than $1,000 less than annual salary rounded down to the nearest $1,000. Please Check One: Smoker Non-Smoker Yes, I have been tobacco free for the past 12 months and choose the lower optional life insurance rates. For Changes Only LAST NAME FIRST NAME MI SSN (REQUIRED) DATE OF BIRTH SEX RELATIONSHIP Add Drop / / M F Add Drop / / M F Add Drop / / M F Add Drop / / M F Add Drop / / M F FORMER SPOUSE INFORMATION If Listed Above Date of Divorce: / / Are you remarried? Date of your remarriage: Has your former spouse remarried? Date of former spouse s remarriage: Yes No / / Yes No / / Address: Street City State Zip SIGNATURE REQUIRED AUTHORIZATION I have read the instructions on the reverse side of this form and authorize my employer, or direct my pension authority, to deduct from my payroll or pension check the amount required for the coverage I have selected. I understand that due to IRS regulations, my health insurance coverage elections are binding for the duration of the plan year and that I may only enroll in health insurance or change my coverage elections during the plan year if I experience a qualifying status change (examples include marriage, adoption/birth of a child, death of a dependent, and involuntary loss of other coverage). I understand that the GIC must receive any required documentation for health insurance changes within 60 days of the event. Family status change documentation for optional life enrollment and changes must be received by the GIC within 31 days of the qualifying event. Signature of Applicant: Signature of Authorized Official: For GIC Use Only Date: Date: Entered Verified Political Subdivision (See over for Form-1 instructions) 1-3/17

3 ENROLLMENT/CHANGE FORM (FORM-1) INSTRUCTIONS For an overview of your GIC benefit options, see your GIC Benefit Decision Guide mass.gov/gic/bdgs. Deadlines and Required Documentation Required Documentation: To add a spouse or dependent to coverage, documentation is required. Refer to dependent information section below for details. New Hire: Completed paperwork and required documentation must be received by your GIC Coordinator no later than your 10th calendar day of regular, benefit eligible employment. If you miss the deadline, you must wait until the next Annual Enrollment period to enroll in GIC basic life and health insurance benefits. Annual Enrollment: Completed paperwork and required documentation must be received by your GIC Coordinator (active employees) or the GIC (retirees and survivors) by the end of the Annual Enrollment period. Qualifying Family Status Change for Optional Life: State employees actively at work who have the following qualifying family status changes during the year may enroll in or increase their optional life insurance coverage without any medical review in an amount not to exceed four times their salary: marriage, birth/adoption, divorce and death of a spouse. Proof of the qualifying event and the completed form must be received by the GIC within 31 days of the qualifying event. You must already have basic life insurance for this option. Forms received after 31 days are subject to proof of good health. Qualifying Status Change for Health Insurance: State employees and retirees who have a qualified status change during the year can enroll in GIC health insurance or change from individual to family coverage or family to individual with proof of the family status change. Documentation of the event and the completed form must be received at the GIC within 60 days of the qualifying event. Forms and documentation received after 60 days are returned and you may re-apply during Annual Enrollment. Return from FMLA or Military Leave: If you voluntarily canceled GIC health insurance coverage at the beginning of your FMLA or military leave of absence, you can re-enroll in GIC basic life and health insurance coverage upon your return from leave. Optional Life and Long Term Disability are subject to evidence of insurability unless you are returning from a military leave. The enrollment form must be received at the GIC within 60 days of the return to work. Forms received after 60 days are returned and you may re-apply during Annual Enrollment. Work Hours and Eligibility Active state employees must work at least hours in a 37.5-hour workweek or 20 hours in a 40-hour workweek and must contribute to your Employer s public sector retirement system. For GIC purposes, OBRA is not such a retirement system. For additional eligibility details, refer to the GIC s Regulations: mass.gov/gic/regulations. Long Term Disability New state employees can enroll within 10 days of hire in Long Term Disability without providing evidence of good health. Current active state employees can apply at any time, but are subject to proof of good health. Optional Life Insurance New state employees can enroll within 10 days of hire in Optional Life Insurance for a coverage amount of up to eight times your salary without the need for any medical review. Current active state employees can apply at any time, but must have basic life insurance and are subject to proof of good health. If you select an amount of Optional Life Insurance that is a multiple of your salary of two to eight times, up to $1.5 million maximum, you will be enrolled in the Automatic Increase; your Optional Life Insurance coverage will increase automatically after an increase in your salary. If you elect to change from a fixed amount (where your coverage does not increase as your salary increases) to Automatic Increase, you will be subject to proof of good health. Dependent Information and Required Documentation In order to enroll your eligible spouse, former spouse and/or dependents in GIC health insurance, you must enter their information in the spouse/dependent box and provide a copy of a marriage certificate, birth certificate or hospital announcement letter (newborns only), separation agreement, divorce decree, certificate of appointment as legal guardian, etc., for each person you list as a dependent. If covering a former spouse, also complete the former spouse information section. Failure to provide required documentation with this enrollment/change form will result in your spouse/dependent not being covered. If you are deleting a spouse or dependent under age 19, you must do so during Annual Enrollment or within 60 days of a qualifying event. Under federal health care reform, Social Security Numbers must be provided for each spouse/dependent to be covered under the health plan. For a newborn only, the Social Security Number can be provided at a later date. Please indicate the exact date of birth for each dependent. To cover a dependent age 19 to 26, you must also provide a completed Dependent Age 19 to 26 Enrollment and Change Form. Form and Documentation Submission Incomplete forms and insufficient required documentation may result in no coverage or a delayed effective date. Active employees: Return completed form and documentation to your GIC Coordinator. Retirees: Return completed form to the GIC, P.O. Box 8747, Boston, MA (See over for Form-1) 3/17

4 GIC LIFE INSURANCE BENEFICIARY FORM-319 For one to three beneficiaries (I'\Commonwealth of Massachusetts -Group Insurance Commission Insured GIC ID (Usually Soc. Sec. No.)! Insured Name: First Agency/Division I M.I. Last Street Address City State Zlp Code Country (if not USA) YOU MUST READ INSTRU010NS ON BACK BEFORE COMPLETING FORM - PRINT CLEARLY IN CAPITAL LETTERS Street Address a Same as Insured a Brother/Sister 1-...,_,..,, ,._...._ _. +-_.._ _..,_--+-.._..._...,_,..,,.'--..._-1 a Other, specify: City State Zip Code Country (If not U.S.A.) Social Security Number % OF PROCEEDS (Do Nat Put S Amount) a Parent _..._._~ _~ _..._~ ~_ _... ~ _,..._-1achlld Street Address a Same as Insured a Brother/Sister _..._..._......,..._...._...._....._,....._ _, ,,._..._ Cl Other, specify: City State Zip Code Country (if not U.S.A.) % OF PROCEEDS (Do Not Put S Amoulll) a Parent Street Address a Same as Insured Cl Child a Brother/Sister._......_...._ ,._, _--+-._,...._ _...._......_..._ Cl Other, specify: City State Zip Code Country (if not U.S.A.) Social Security Number Date of Birth ' I I Phone Number (Optional) % OF PROCEEDS (Do Nat Put s Amountl I hereby make the above designation of beneficiary revoking any and all previous beneficiary nominations and make the above nomination of beneficiary with respect to all insurance provided now or al any time in the future under the group insurance pollcles. I still reserve the privilege of making other and future changes subject to the policy provisions. If more than one beneficiary Is designated, settlement will be made in equal shares to each of the designated benerciary(ies) that survive me, unless otherwise provided herein. II no designated beneficiary(les) survive me, settlement will be made as provided in the policy In the following order: to the spouse, then to the children, then to the parents, then to the siblings, then to the estate. For GIC Use Only Fonn 319: 1/2017 Signature of Insured PLEASE MAKE A COPY OF THIS COMPLETED FORM AND FILE WITH YOUR IMPORTANT RECORDS. I Entered I Verified Please return form to: Group Insurance Commission, P.O. Box 8747, Boston, MA (See over for Form-319 instructions) Date

5 , GIC LIFE INSURANCE BENEFICIARY FORM-319 INSTRUCTIONS PLEASE READ ALL INSTRUCTIONS AND EXAMPLES CAREFULLY BEFORE COMPLETING THIS FORM. 1. Please print all beneficiary information clearly in capital letters on the lines provided, indicating your beneficiary's name, relationship, Social Security number, date of birth, address and the percentage of proceeds to be paid to each beneficiary. Incomplete forms will be returned. Refer to the samples illustrated to the right to assist you in the completion of your form. 2. If you do not provide a percentage of proceeds for your beneficiaries, the proceeds will be divided equally among all listed beneficiaries. If you provide a percentage for some but not all of the listed beneficiaries, your form will be returned to you to complete. DO NOT PUT A DOLLAR AMOUNT IN THE "% of Proceeds" BOX. Q.. -..,... 1DO!I. Cl- "-"'-""-'-'-'-L.JL...l...l-l...-'-1-...L-L...L...L-"'-----l.=!!...!..l.!..l!.!L..L-L.-'-'-...I.-L-'-'...LJ'-'-L-jc,- l=e-"'-l...i..!j>= """-'.!..1!!."""""-l!..L...il!1>'-'-4...Lf~L...l...'-+,.i...L..L.l...L.L...L...L---L-jOOO-. - a.,r,tnociioi.,_ l-'-.j...j...-'-'-...l-l...1.-l...l...1_,...,_.,._..,_...1.-l,,..._...,_..._ l-l-'-la- a- 1--'-J...L..i...L...L-L...L-l.,._j_...J_, L-I...J...L.-'--!--"-j-='"::-'-L...l'-f-L...L...l..-L.~..J-L..J.-.jCI Cdw, _,... 0,,_ 3. Use this form to designate up to three beneficiaries. If you wish to list more than three beneficiaries, an estate or trust, DO NOT use this form. Instead, you must obtain a GIC Life Insurance Beneficiary Form G-500 from your GIC Coordinator and use that form to list all your beneficiaries. If you are a retiree and need a G-500, please call Ext If you list beneficiaries who have the same last name as you, DO NOT write their last name. Instead, simply mark an "X" in the usame as Insured" box for each beneficiary who has the same last name as yours. 5. If you list beneficiaries who live at the same address as you, DO NOT write in their address. Instead, simply mark an "X" in the "Same as Insured" box for each beneficiary who lives at your address. 6. Please sign and date the form clearly, in ink, where indicated. Keep a copy of the completed form with your important papers. 7. Please return this completed form to the Group Insurance Commission, P.O. Box 8747, Boston, MA The effective date of an enrollee's life insurance beneficiary designation is the date that the GIC receives the completed beneficiary form. If you list two or more beneficiaries with a specific percentage designated to each, proceeds will be paid as you designated. If one of the beneficiaries dies before you, proceeds will be paid to the remaining beneficiary/beneficiaries. If you list more than one beneficiary and indicate 100% for each one, this means that when you die, the first beneficiary will receive 100% of the proceeds. However, if the first beneficiary dies before you, the second designated beneficiary will receive 100% of the proceeds. If the second beneficiary also dies before you, your third beneficiary will receive 100% of the payment. If all designated beneficiaries die before you, payment will be made according to the terms of your life insurance policies in effect at the time of your death. (See over for Beneficiary Form-319) Fann

6 ~-., -."""'---~ DEPENDENT AGE 19 TO 26 ENROLLMENT/CHANGE FORM - FEDERAL HEALTH CARE REFORM (ACA) Use this form to enroll your dependent age J9 to 26 for the first time or to report your dependent's age 19 ta 16 status change. Upon rttelpt of a complete oppllcatlon, the GIC wlll determine coverage ellglblllty and effective date. For new Insureds, coverage for the dependent age J9 to 26 will begin on the new lnsund's effective date. Dependents of existing GIC enrollees who an already over age 19 must have a qualifying event ta enroll during the year or may apply during the GIC's Annual Enrollment. Incomplete appllcatlons wlll be returned. PLEASE USE ONE FORM FOR EACH DEPENDENT AGE 19 TO 16. I am applying for coverage or reporting a status change for my dependent age 19 to 26. The GIC may require proof of relationship for the dependent you plan to cover and will contact you for any documents, If necessary. Name of Insured Address City State Zip Social Security#,/ / Telephone# PLEASE COMPLETE ONLY ONE SECTION BELOW SECTION A- ENROLL YOUR DEPENDENT SECTION B - CHANGE DEPENDENT STATUS A) ENROLLMENT DEPENDENT AGE 19 TO 26 Use this section to enroll your dependent Name of Dependent Age Social Security# ~!! Address City State Zip Dependent's Date of Birth_}_) Relationship to Insured , Check here if your dependent is a full-time student attending an accredited institution outside your health plan's service area and provide school name and address below: (Check with your health plan for benefits available to full-time students that are attending school outside the service area.) Name of School School Address (That is outside health plan's service area) You must contact the GIC when your dependent is no longer a full-time student to continue coverage to age 26. B) CHANGE OF DE PEN DENT'S AGE 19 TO 26 STATUS use this section to report dependent address and full-time student status changes Name of Dependent Age Social Security# I! Address City State Zip Dependent's Date of Birth_}_) Relationship to Insured Dependent Address Change New Address: Dependent is no longer a full-time student as of (Date) SIGNATURE REQUIRED Please sign and date below I understand that If my dependent Is not a full-time student he/she must reside In my health plan's service area. If you are not sure, the GIC health plan service areas are listed In the GIC Benefit Decision Gulde (available on our website, or you may contact your health plan directly. If your dependent does not live In your health plan's service area and Is not a full-time student, you must change health plans. The UnlCare Indemnity Plan Basic Is the only nationwide plan. Under the pains and penalties of perjury, I attest that all statements I have made an this form are true. I understand that if I misrepresent or provide false or Incomplete Information on this form my GIC coverage may be terminated (possibly retroactively}, In addition to other legal remedies and financial consequences, at the GIC's discretion. Signature of Insured Date Return to: Group Insurance Commission, PO Box 8747, Boston, MA GIC USE ONLY APPROVED Effective Date Expiration Date DENIED Revised 3/17

7 Group Insurance Commission Flexible Benefit Plan Enrollment Form Plan Year: July 1, 2017 to June 30, ½ Month Grace Period: July 1 - September 15, 2018 Claim Filing Deadline: October 15, 2018 EMPLOYEE: Fill out Sections A through E and return completed form to your Payroll/Benefits Coordinator A. Employee Information Please Print Clearly! Name: Social Security Number (Required): Address: Daytime Phone: City: State: Zip Code: Employee ID#: Date of Birth: Agency Name: UMass Amherst (Required): B. Flexible Benefit Plan Pre-tax Elections 1. Health Care Spending Account (HCSA) Eligible health expenses include medical, dental, vision and hearing expenses incurred by my dependents or myself during the Plan Year for the diagnosis, cure, mitigation, treatment or prevention of disease, or for the purpose of affecting any structure or function of the body. See IRS Publication 502 for more information. $ X = $ Your Contribution Per Pay Period # of Pay Periods Total Election Election Allowed per Plan Year $250 minimum/$2,600 maximum 2. Dependent Care Assistance Program (DCAP) Eligible dependent care expenses must be work-related and incurred to allow me and, if applicable, my spouse to be gainfully employed. Qualifying dependents include children under age 13 or older dependents who are not capable of self-care. Please remember that the IRS will require you to disclose the Tax ID or Social Security Number of your day care provider(s) when you file your income taxes. See IRS Publication 503 for more information. $ X = $ Your Contribution Per Pay Period # of Pay Periods Total Election Maximum Election Allowed per Tax Year $5,000 / $192.30/Biweekly pay period ($2,500 if married and filing separately) C. ASIFlex Card HCSA participants will automatically receive two debit cards. A $5.00 fee will be assessed annually for additional/replacement card sets and billed directly to your HCSA. Please indicate the number of additional card sets you would like to request below. (You will automatically get 2 cards to start). Please note that cards are ordered in multiples of 2. (Example: 2, 4, 6, 8, etc.) Additional Card Sets Requested: REQUIRED: You must indicate the medical plan in which you have enrolled. Please check the appropriate box. If not enrolled in a GIC plan, check the last box. Fallon Health Direct Care HMO Fallon Health Select Care HMO Harvard Pilgrim Independence Plan POS Harvard Pilgrim Primary Choice Plan HMO Health New England HMO NHP Care (Neighborhood Health Plan) Tufts Health Plan Navigator POS Tufts Health Plan Spirit EPO (HMO-Type) UniCare State Indemnity Plan/Basic UniCare State Indemnity Plan/Community Choice (PPO-type) UniCare State Indemnity Plan/PLUS (PPO-type) Not enrolled in any plan listed D. Direct Deposit Authorization Claim payments can be sent directly to a bank account of your choice, and you can be notified by /text alert each time a payment is issued. Bank Name: (See #1 on sample) Routing Number - 9 digits: (See #2 on sample) Account Number: (See #3 on sample) Checking Account Savings Account SAMPLE Cell Phone: Mobile Carrier: E. Signatures By signing below, I agree to the following Terms and Conditions stated on the opposite side of this form. Employee Signature (Required): Date: REQUIRED: The section below must be completed, in full, by agency Payroll/Benefits Coordinator Benefit Effective Date: DCAP: / / HSCA: / / Date of Qualifying Event: / / Beth A. Ives bives@admin.umass.edu Payroll/Benefits Coordinator: Division Code: (ex: ABC1234) UMS / Address: Phone #: Reason for Enrollment: Open Enrollment New Hire x Qualifying Status Change: PAYROLL/BENEFITS COORDINATORS: Fax or Upload completed form to ASIFlex, not the GIC Page 1 of 3 FSA 3/17

8 Enrollment Form Instructions Section A Section B Section C Section D Section E Employee Information - Please print your name and complete address clearly. Your phone number and address will be used only to communicate with you with regard to this plan. It will not be distributed to any other organization or used for marketing purposes in any way. Statements of your account balance and activity will be sent via /text alert whenever possible. Please understand that this is an employee account and due to federal and state laws we cannot release detailed information to anyone other than the participant (employee). Please contact our office for further information or you can sign a HIPAA release to allow others to act on your behalf and obtain information. Flexible Benefit Pre-Tax Elections - 1. Health Care Spending Account (HCSA) - Carefully consider how much money you would like to set aside each pay period during the Plan Year to pay for your family s eligible out-of-pocket medical expenses. Make sure you read your Participant Handbook to fully understand how the plan works. 2. Dependent Care Assistance Program (DCAP) Carefully consider how much money you would like to set aside each pay period during the Plan Year to cover the expenses you will incur to care for your eligible dependents while you and your spouse (if applicable) are gainfully employed. Qualifying dependents are children under age 13 or older dependents not capable of self-care. Make sure you read your Participant Handbook to fully understand how the plan works. ASIFlex Card - You may order an additional set of cards for other eligible dependents if desired. A fee of $5.00 per additional set will be assessed to your HCSA for each set of cards. Cards are reloaded over plan years, so if you already have a debit card from a prior plan year, it will be loaded with your election funds. You will not receive new cards unless requested. Direct Deposit Authorization - If you would like your reimbursements sent directly to your checking or savings account via Direct Deposit, fill out this section and attach a voided check (for checking) or deposit slip (for savings). Confirmations are sent via /text alert and will show current transaction information, as well as, available funds in the account. Signatures - After you have completely filled out this form and carefully read the following Terms and Conditions please sign and date then return the enrollment form to your payroll office as applicable. Employers must review the elections and sign that the employee meets the eligibility requirements. Flexible Benefit Plan Terms and Conditions I UNDERSTAND THAT: By participating in the Flexible Benefit Plan, my employer will deduct pre-tax from my pay check: $2.50 per month from the first paycheck of each month and my election amount equally divided by the number of pay periods within the plan year. I cannot change this election during the Plan Year unless I have a qualifying change in status as described in the Plan document. I must make all of my elections carefully and conservatively. The IRS imposes a strict use-it-or-lose-it rule, which means money left in a pre-tax account at plan year end is forfeited. Expenses paid under the HCSA or DCAP cannot be reimbursed from any other source and that I will not seek reimbursement from any other source. Expenses must be incurred during the Plan Year or the Grace Period. The Grace Period is a 2 ½ month period following the end of the Plan Year during which I may continue to incur expenses for the prior plan year. (September 15, 2018) All FY18 plan year claims must be submitted by the claim filing deadline, called a run-out period, which ends October 15, The IRS imposes a strict use-it-or-lose-it rule, which means money left in a pre-tax account at the plan year end is forfeited. Qualifying expenses are those incurred by me, or by my legal dependents. HCSA expenses can be reimbursed up to the plan year election, less prior reimbursements. DCAP expenses can be reimbursed up to the year-to-date deposits, less prior reimbursements. The ASIFlex Card can be used only for qualifying health care expenses as defined by IRS guidelines. The IRS requires me to keep documentation of all my card transaction expenses and submit documentation to the administrator upon request. If I do not provide the requested documentation as required, IRS regulations require that the card be temporarily deactivated. Claims submitted will be offset by any outstanding card transaction amount. Misuse of the card may result in permanent revocation and repayment of ineligible expenses. If I have not selected to be reimbursed by Direct Deposit, I am accepting to receive reimbursement check by mail to my address on file. I understand that reimbursements will accumulate until a minimum of $25.00 is met. A reimbursement check will not be issued for an amount below $25.00; unless the plan year has ended. I understand additional details are outlined in participant handbook available at asiflex.com/gic. ASIFlex PO Box 6044 Columbia, MO Toll-free: Fax: asi@asiflex.com Page 2 of 3 FSA 3/17

9 Important Information Regarding Enrollment and Changes ADMINISTRATIVE FEE The cost to administer this program is paid for by each employee on a before tax basis. The monthly administrative fee is $2.50 for any account participation for Health Care Flexible Spending Account (HCSA) alone, Dependent Care (DCAP) alone or for HCSA/DCAP combined. ELIGIBILITY AND ANNUAL MAXIMUM AND MINIMUM FOR HCSA AND DCAP HCSA: Active state employees who are eligible for GIC benefits. Enrollment must be elected within 10 days from your date of hire. The waiting period is the same as for other GIC life and health benefits; coverage effective the first of the month following 60 days or 2 calendar months. Minimum $250; Maximum $2,600. DCAP: Active state employees who are eligible for GIC benefits who work at least hours per 37.5 hour work week or 20 hours per 40 hour work week. You are eligible on the first day of employment. Enrollment forms must be submitted to your Payroll Coordinator within 10 business days from your date of hire. Maximum $5,000 at beginning of plan year, $ per biweekly pay period mid-year ($2,500 if married filing separately). CHANGE IN STATUS Elections may be changed during open enrollment. You may only change your election mid plan year if you experience a change in status as defined in the Plan. Only the following events will be considered a valid change in status under Internal Revenue Service rules. Change in legal marital status Change in number of dependents Change in employment status that changes your eligibility for the program Change in work schedule, which changes your eligibility for the program Dependent satisfies or ceases to satisfy eligibility requirements Judgment decree or order pertaining to child or spouse If you would like to terminate your elections as a result of a valid change in status, enter a zero dollar amount in the HCSA/DCAP section(s) of the enrollment form. Payroll Coordinators must obtain the appropriate supporting documentation of a Change in Status, such as a copy of the marriage or birth certificate. Please see the current plan year Participant Handbook for additional information and information regarding Leaves of Absence and Leaving State Service. Forms must be submitted within 60 days of the qualifying event. SIGNATURE AND FORM SUBMISSION The employee and Payroll/Benefits Coordinator must sign this form. All forms must be submitted to the Payroll Office at your work site. The Coordinator must send the original form to ASIFlex. Please do not send completed forms to the GIC. ELIGIBLE EXPENSES UNDER A DEPENDENT CARE ASSISTANCE PLAN Eligible expenses under a Dependent Care Assistance Plan are defined as those that are work-related as defined in the regulations and enable the participant and the participant s spouse to work or to look for work, and are incurred for the protection and well-being of the dependent. Dependents must be under the age of 13 or, if older, not capable of self-care. Qualifying providers and expenses include: Child Care centers that care for six or more children and that meet the IRS definition of a qualified day care center. Caregivers for a disabled spouse or dependent who lives with the participant and is not capable of self-care. Babysitters for work-related expenses Before school or after school care Day Camp (not overnight camps) Household expenses provided that a portion of such expenses are incurred to ensure a qualifying dependent s well-being and protection. Note: Please see IRS Publication 503 additional information. In compliance with the IRS guidelines, the service provider cannot be an individual for whom a personal tax exemption may be claimed. In addition, a child of the participant or spouse cannot be under the age of 19. IRS calendar year pre-tax maximum is $5,000. INELIGIBLE EXPENSES UNDER A DEPENDENT CARE ASSISTANCE PLAN Expenses for services not yet provided, even if you must pay in advance Babysitting for social events, or services that are not work-related as defined by the IRS Educational or tuition expenses (kindergarten, first-grade or higher) Overnight camp, summer school, lessons (dancing, musical, etc.) Expenses incurred while you are not working or looking for work Note: If you are divorced, only expenses incurred by the custodial parent may be considered ELIGIBLE EXPENSES UNDER A HEALTH CARE SPENDING ACCOUNT Eligible expenses under a HCSA are defined as those that are medically necessary, prescribed by a licensed practitioner and are not reimbursed under another program. Eligible expenses are listed in the Participant Handbook available on the GIC s web site, Don t forget that expenses such as insurance premiums may be deductible on Schedule A tax return, but not eligible for reimbursement through a HCSA. Some examples of eligible expenses are: acupuncture, ambulance, artificial limbs, contact lenses, health plan deductibles, dental expenses, health and RX co-pays, hearing aids, vision expenses, over-the-counter health care products, and more. Additional information is also located at INELIGIBLE EXPENSES UNDER A HEALTH CARE SPENDING ACCOUNT Expenses for services not yet provided, even if you must pay in advance Expenses paid under any other source (such as another insurance plan) Cosmetic treatments, medications or surgery (such as teeth whitening, face lifts, hair transplants, etc.) Expenses for general health and well-being (such as fitness programs, exercise equipment, health club memberships, etc.) Insurance premiums Expenses that are not properly substantiated. Page 3 of 3 FSA 3/17

10 State Employee Acknowledgement Form For GIC Eligible Employees You are responsible for familiarizing yourself with your benefit options and making your elections within 10 days of the date of hire: Basic Life Insurance Basic Life & Health Insurance Summary of Benefits and Coverage ( Optional Life Insurance Long Term Disability (LTD) Dental/Vision (if eligible) Health Care Spending Account (HCSA) Dependent Care Assistance Program (DCAP) Your signature is required on this form before your agency can process your benefit elections. Please sign, date and return this form to your GIC Coordinator after you have reviewed the Benefit Decision Guide. I hereby acknowledge that I have reviewed the most recent GIC Benefit Decision Guide and understand my benefit options before I made my benefit elections. I understand that if I enroll in GIC basic life or basic life and health insurance, my premiums will be deducted on a pretax basis unless I elect post tax benefits. Name: (Please print) Signature: Date: Employee: Return this signed form to your GIC Coordinator with your benefit elections. GIC Coordinator: Give employee a copy of this form and retain original signed form in employee s personnel file. Do not send to the GIC. 9/13

11 Social Security Administration Statement Concerning Your Employment in a Job Not Covered by Social Security Employee Name Social Security# xxx-xx- Employer Name Employer ID# Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be affected. Windfall Elimination Provision Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as a result of this provision is $ This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional information, please refer to Social Security Publication, Windfall Elimination Provision. Government Pension Offset Provision Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension. For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, Government Pension Offset. For More Information Social Security publications and additional information, including information about exceptions to each provision, are available at You may also call toll free , or for the deaf or hard of hearing call the TTY number , or contact your local Social Security office. I certify that I have received Form SSA-1945 that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social Security Benefits. Signature of Employee Date Form SSA-1945 ( ) Destroy Prior Editions

12 Information about Social Security Form SSA-1945 Statement Concerning Your Employment in a Job Not Covered by Social Security New legislation [Section 419(c) of Public Law , the Social Security Protection Act of 2004] requires State and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not covered under Social Security. The statement explains how a pension from that job could affect future Social Security benefits to which they may become entitled. Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential effects of two provisions in the Social Security law for workers who also receive a pension based on their work in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker s Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social Security benefit received as a spouse, surviving spouse, or an ex-spouse. Employers must: Give the statement to the employee prior to the start of employment; Get the employee s signature on the form; and Submit a copy of the signed form to the pension paying agency. Social Security will not be setting any additional guidelines for the use of this form. Copies of the SSA-1945 are available online at the Social Security website, Paper copies can be requested by at ofsm.oswm.rqct.orders@ssa.gov or by fax at The request must include the name, complete address and telephone number of the employer. Forms will not be sent to a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. The forms are available in packages of 25. Please refer to Inventory Control Number (ICN) when ordering. Additional Contact information Information for forindividuals local Social Employed Security by Administration the University of Office: Massachusetts Amherst 200 High Street, 2nd Floor Optional Retirement Program Holyoke, MA Social Security Administration Windfall Elimination Provision and Government Pension Offset calculations for Commonwealth Telephone: (413) Optional Retirement / TTY Program (413) (ORP) members account are based on the balance of the ORP account at the time Commonwealth employment ends. We recommend that ORP members obtain an account balance statement from their vendor at the time Commonwealth employment ends and retain this document for Social Security purposes. Exemption from Windfall Elimination Provision Individuals with 30+ years of significant earnings under Social Security, or who were first eligible to retire from the Massachusetts State Employees Retirement System prior to January 1, 1986, are currently exempt from the Windfall Elimination Provision. Social Security s definition of significant earnings changes yearly (e.g. significant earnings is defined as $5,100 in 1980, $16,725 in 2005.) Please contact Social Security directly to confirm your years of significant earnings. Contact Information for Local Social Security Offices: Social Security Administration 200 High Street, 2nd Floor Holyoke, MA Telephone: (413) TTY: (413) Form SSA-1945 ( )

13 T H E C O M M O N W E A L T H O F M A S S A C H U S E T T S State Board of Retirement O N E W I N T E R S T R E E T, 8 T H F L O O R, B O S T O N, M A NEW MEMBER ENROLLMENT FORM SECTION A To be filled out by employee (Please print or type, except for signature). 1 Name Maiden Name S.S.N. Street Address City, State, Zip Code D.O.B. / / Sex M F Phone # ( ) Marital Status Married Single Widowed Divorced Spouse D.O.B / / Number of Children Are you a Veteran? Position Yes No Start Date Dates of Military Service Agency or Department University of Massachusetts Amherst A COPY OF A MILITARY DISCHARGE MAY BE REQUESTED Agency Phone # ( ) The retirement law establishes specific periods of active service, which may qualify you for certain Veteran benefits. 2 Past membership history with any other contributory retirement system in Massachusetts. RETIREMENT SYSTEM FROM TO WAS REFUND TAKEN? YES YES YES YES NO NO NO NO 3 Are you currently or have you ever received a retirement allowance from another public retirement system? YES NO 4 Statement and Signature By Member I certify the above information to be true and correct to the best of my knowledge and hereby accept membership in the Massachusetts State Retirement System. This statement is signed under penalties of perjury. (Date) (Signature) (continues on reverse) Please return completed form (Section A questions 1 5) to: State Board of Retirement, One Winter Street, 8th Floor, Boston, MA Section B question 6 (on reverse) to be completed by the Agency.

14 SECTION A (Continued) 5 Beneficiary Information Beneficiary or beneficiaries nominated will receive in the proportion designated any sum due at your death. The right to change any nominated beneficiary is reserved by the member. A BENEFICIARY WITH CORRECTIONS OR ERASURES IS NOT ACCEPTABLE Name: GIVE COMPLETE NAME AND ADDRESS OF EACH BENEFICIARY Designation: Proportion:* Date of Birth: Street: City, State, ZIP: Primary Contingent All % (Percent) Relationship: Beneficiary Social Security #: Name: Designation: Proportion:* Date of Birth: Street: City, State, ZIP: Primary Contingent All % (Percent) Relationship: Beneficiary Social Security #: Name: Designation: Proportion:* Date of Birth: Street: City, State, ZIP: Primary Contingent All % (Percent) Relationship: Beneficiary Social Security #: Name: Designation: Proportion:* Date of Birth: Street: City, State, ZIP: Primary Contingent All % (Percent) Relationship: Beneficiary Social Security #: Name: Designation: Proportion:* Date of Birth: Street: City, State, ZIP: Primary Contingent All % (Percent) Relationship: Beneficiary Social Security #: (Date) (Signature) (Signature of Witness) *Must Total 100% If Contingent Please Specify (A CHANGE IF BENEFICIARY FORM must be used if you wish to change your designated beneficiary/beneficiaries. You may obtain this form from your payroll department or from the Board of Retirement) SECTION B To be completed by the Agency: 6 POSITION DEDUCTION SERVICE STATUS 5% Full-Time 7% Part-Time % Start Date 8% Temp/Sub: Start Date 9% STATE POLICE Start Date 12% Date of First Deduction New Transfer 30 Plus Other University of Massachusetts Amherst (Agency Name and Payroll Number) UMS 0147 (Authorized Signature)