EMPLOYEE INFORMATION. Marriage of employee (M) Legal Separation (V) Birth of child (B) Divorce or Annulment (Q) Divorce decree / Annulment cert.

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EMPLOYEE INFORMATION Name: Change in Status/Special Enrollment Request Form For use in processing Qualifying Events: benefits election changes, adding and/or dropping dependents.

1 EMPLOYEE INFORMATION Name: Change in Status/Special Enrollment Request Form For use in processing Qualifying Events: benefits election changes, adding and/or dropping dependents. Must be submitted w ithin 60 days from the date of the Qualifying Event Please fax signed copy and supporting documentation to: (866) or to:status_change@adp.com Worksite Employer Name: Address: City, State Zip Code SS#: Birth Date: Gender: Male Female DATE OF EVENT: Best Number to call: Notification Requirement & Effective Date If you experience a qualified change-in-status or special enrollment event, ADP TotalSource must receive this Change in Status/Special Enrollment Request Form and supporting documentation w ithin 60 days of the event, or you w ill not be permitted to make benefit elections changes until the next annual open enrollment period (i.e., June 1 st ). Please note that this form w ill not be processed w ithout the proper proof of status change documentation (see examples in the Status Change Information section of this form). The documentation must contain your and/or your dependent(s) name, along w ith the date of the qualified change-in-status or special enrollment event. You should contact the Employee Service Center at (800) if you are unsure w hat supporting documentation is acceptable to support your change-in-status or special enrollment event. All approved benefit election changes as a result of a qualified change-in-status or special enrollment event w ill become effective on the first day of the month follow ing ADP TotalSource s receipt of this form and your proof of change-in-status or special enrollment event. In the event of a birth, adoption, or placement for adoption, the new dependent w ill be added retroactive to the date of birth, adoption, or placement for adoption. Note: If you or your dependent(s) have experienced one or more of the follow ing events, you must submit the applicable form listed below, along w ith this form: Obtained other group health, dental or vision coverage and requesting to drop coverage; please also complete the Certification of Other Group Health, Dental, Vision Plan Coverage form. Experienced a loss of premium tax credit for purchase of health insurance through a Health Insurance Marketplace and requesting to enroll in coverage; please also complete the Loss of M arketplace Premium Tax Credit Certification form. Note: enrollment w ill be on a post-tax basis until the next annual open enrollment period. Change in Status Consistency Rules IRS regulations require your enrollment changes to be consistent w ith your qualified change-in-status event. ADP TotalSource w ill advise you if your enrollment change request is inconsistent w ith these regulations. The Employee Service Center and your human resource representative can assist you in determining w hich election changes satisfy the IRS regulations pertaining to consistency. Any application of a permissive change-in-status rule must conform to consistency requirements under the regulations and to the terms of any applicable insurance policy, including any HMO contracts if applicable. Please refer to the Summary Plan Description for additional information. STATUS CHANGE INFORMATION Place a in the box below that corresponds to your change-in-status or special enrollment event. Proof of your change-in-status or special enrollment event is required. Please refer to the list of Acceptable Documentation options for each of the corresponding events below. Event Acceptable Documentation Event Acceptable Documentation Marriage certificate or license (if Marriage of employee (M) adding spouse and/or Legal Separation (V) Court order of legal separation dependent(s)) Birth of child (B) Birth certificate or hospital certificate Divorce or Annulment (Q) Divorce decree / Annulment cert. Change in Dependent Employment (E or T) Dependent Gains Eligibility (2) Adoption/Legal Guardianship (A) Placement for Adoption (N) Death of Dependent (C or D) Loss of Dependent Eligibility (G) Letter on employer letterhead with start or end date of benefits eligibility or Certification of Other Coverage form Certification of eligibility if required under State law Court documentation of adoption or legal guardianship Agency Certification of placement Death certificate or funeral home/burial certification No supporting documentation needed Qualified Medical Child Support Order (QMCSO) (Z) CHIPRA (U) Change in Residence (3) Medicare or Medicaid Entitlement (F) Loss of other health coverage (Special Enrollment) (L) Open Enrollment for dependent excludes Marketplace Open Enrollment(W) Written notice from govt. agency Written notice from govt. agency Proof of new address (utility bill, lease agreement, etc.) Notice from govt. agency or ID Card Creditable coverage certificate or letter on employer letterhead Open enrollment documentation with effective or termination date, ID card, or Certification of Other Coverage 1

2 Gain in Domestic Partner eligibility Loss of Domestic Partner eligibility Notarized affidavit with 2 supporting docs from approved list Completed statement of termination of domestic partnership Loss of Marketplace health coverage (Carrier exits Marketplace or eliminates plan) Loss of Marketplace premium tax credit (post-tax enrollment permitted) Written notice from Carrier or Marketplace Loss of Tax Credit Certification form or written notice from Marketplace Change in Status/Special Enrollment Request Form DEPENDENT INFORMATION: Check the appropriate action box (Add or ) for the Medical, Dental and Vision Plan. If you are adding a dependent to an HMO, POS, or DMO plan, you must include the PCP ID number. *Please note HIPAA Special Enrollment periods only apply to the Medical Plan. Refer to the Summary Plan Description for further details. LAST NAME, FIRST NAME DATE OF BIRTH RELATION Employee SOCIAL SECURITY # MEDICAL Check One DENTAL* Check One VISION* Check One MEDICAL REIMBURSEMENT ACCOUNT* I w ish to enroll. Annual Election $ I w ish to increase or decrease my annual contribution. New Annual Election $ DEPENDENT CARE REIMBURSEMENT ACCOUNT* I w ish to enroll. I w ish to cancel. Annual Election $ I w ish to increase or decrease my annual contribution. New Annual Election $ HEALTH SAVINGS ACCOUNT (HSA) Note: Changes to your HSA elections are permitted throughout the plan year without restrictions. I w ish to increase or decrease my monthly HSA contribution. New Monthly Election $ I w ish to stop my HSA deductions. HIPAA Special Enrollment Rights Loss of Other Coverage The HIPAA special enrollment period only applies to medical plans, therefore, you may only make changes to your medical plan election (changes to dental, vision, FSA or life elections are not permitted). You must satisfy the follow ing conditions to qualify for a special enrollment under HIPAA due to a loss of other health coverage: 1. You w ere covered under another group heath plan or other heath insurance w hen the ADP TotalSource Health and Welfare Medical Plan w as first offered to you; and 2. You indicated on the ADP TotalSource Health and Welfare Plan enrollment form that you declined medical plan enrollment because you had other medical plan coverage; and 3. If you declined to enroll in the ADP TotalSource Health and Welfare Medical Plan because you decided you w anted to continue COBRA as the only coverage, your COBRA coverage period has expired for reasons other than your failure to pay your COBRA premium. AUTHORIZATION 2

3 I authorize the action(s) I have indicated on this form as w ell as necessary payroll deduction changes and understand that any request to change my current ADP TotalSource Health and Welfare Benefits Plan elections w ill require proper documentation and must be submitted w ithin 60 days from the date of the qualified change-in-status or special enrollment event. I hereby certify that the above information is complete and accurate. If you live in California and enroll in a health plan that uses binding arbitration to settle disputes, the follow ing acknow ledgement w ill apply: I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure, and benefits claims subject to ERISA) any dispute betw een myself, my heirs or other associated parties and the health plan, including any claim for medical or hospital malpractice, for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided by binding arbitration under California law and not by law suit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. Subject to the three exceptions noted above, I agree to give up my right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the health plan s evidence of coverage. Signature Date Please submit your completed form and proof documentation to: Fax: (866) Status_Change@adp.com 3

4 Certification of Other Group Health, Dental, Vision Plan Coverage INSTRUCTIONS: If you or your dependent(s) have experienced a change-in-status event whereby you have obtained other group health, dental or vision coverage, please complete this form and fax or it to the number or address specified below, along with a completed Change in Status/Special Enrollment Request Form. I, (Name of Employee), submit this Certification of Other Group Health, Dental, Vision Plan Coverage form to request a change in benefit elections based on a marital or employment change in status under the ADP TotalSource, Inc. Health and Welfare Plan ( Plan ). I certify that the individual(s) listed below currently have medical, dental and/or vision coverage under the Plan, and that I now wish to drop Plan coverage for these individuals because they have obtained other group medical dental vision plan coverage effective due to the following change-in-status event : Change in employee s legal marital status Change in employment status of a spouse or dependent that affects eligibility Open Enrollment under spouse or dependent s employer plan I understand that obtaining individual health plan or health insurance coverage in connection with a marriage or change of employment does not satisfy the IRS change-in-status rules, and certify that the other health, dental or vision plan coverage obtained by the below named individuals is provided through another employer. I understand that once I drop Plan coverage for myself and/or for one or more of my dependent (s) (including a spouse, a domestic partner, or dependent children), I cannot reenroll myself or my dependent(s) for Plan coverage until the next annual open enrollment period or, if earlier, the occurrence of a qualified change-in-status that permits me to reenroll myself and/or my dependents. I understand that providing false or misleading information in this Certification of Other Group Health, Dental, Vision Plan Coverage form may result in loss of Plan enrollment, termination of my employment and other legal action against me. (List the names of the individual(s) for whom coverage under the Plan is being dropped because they have obtained other group health plan coverage) I,, of full age, upon my oath, hereby certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are false or misleading, I am subject to loss of Plan enrollment, termination of employment, and other legal sanctions. Signature of Employee Employee ID Number Date Client Name Paygroup 4

5 FAX OR COMPLETED FORM TO: Fax: (866) Loss of Marketplace Premium Tax Credit Certification Request for Post-Tax Enrollment in a TotalSource Health Plan INSTRUCTIONS: If you or your dependent(s) have lost eligibility for a premium tax credit for purchase of health insurance through a Health Insurance Marketplace, please complete this form and fax or it to the number or below, along with a completed Change in Status /Special Enrollment Request Form. I, (Name of Employee), submit this Loss of Marketplace Premium Tax Credit Certification form to request enrollment in health benefits under the ADP TotalSource, Inc. Health and Welfare Plan ( Plan ) on a post-tax basis. I understand that the loss of eligibility for a premium tax credit does not permit me to contribute towards health coverage I elect through the Plan on a pre-tax basis and that the health plan election I make at this time will result in post-tax contributions (until I elect to change to pre-tax contributions during a future open enrollment period). If I do not make an updated health plan election during a future open enrollment, I understand my health plan contributions will continue to be deducted from my payroll post-tax. I certify that the individual(s) listed below currently have medical coverage through the Health Insurance Marketplace, and that I now wish to enroll the individual(s) in post-tax coverage because they have lost eligibility for a premium tax credit for the purchase of health insurance through the Health Insurance Marketplace effective (insert date premium tax credit eligibility terminates) and date of Marketplace termination notice. I understand that coverage will be effective on I understand that once I enroll in coverage for myself and/or for one or more of my dependents (including a spouse, a domestic partner, or dependent children), I may not drop Plan coverage for myself or my dependents until the next annual open enrollment period or, if earlier, the occurrence of a qualified change-in-status that permits me to drop myself and/or my dependents. I understand that providing false, misleading information in this Loss of Marketplace Premium Tax Credit Certification form may result in loss of Plan enrollment, termination of my employment and other legal action against me. Important Note: If you are already enrolled in ADP TotalSource health coverage and adding a dependent that has lost eligibility for a premium tax credit, this change will result in post-tax benefit deductions for your full premium contribution responsibility. (List the names of the individual(s) that have experienced a loss of premium tax credit eligibility and for whom you are requesting to enroll in health coverage under the Plan on a post-tax basis). I,, of full age, upon my oath, hereby certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are false or misleading, I am subjec t to loss of Plan enrollment, termination of employment, and other legal sanctions. 5

6 Signature of Employee Employee ID Number Date Client Name Paygroup FAX OR COMPLETED FORM TO: Fax: (866)

Stanislaus County Benefit Enrollment Form- 2015

Stanislaus County Benefit Enrollment Form- 2015 Please complete this universal benefit enrollment form in its entirety when enrolling or making changes to your Benefits. Refer to your Benefit Guide for