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47 BENEFITS DEDUCTION AUTHORIZATION FORM Name: Location: SS# Full-time Part-time (30-39 hours per week) Part-time (20-29 hours per week) Temporary Benefit Coverage Effective Date (1st of the month following date of hire): Pre-Tax Payment Plan (see the reverse side for more information) General Government Transfer Type of Coverage Benefit Description Amount from Regular Paycheck (circle one) (circle one) ANTHEM Health Care (CHECK ONE) (check one) STANDARD POS PREMIER POS LUMENOS with HSA WAIVE HEALTH INSURANCE EMPLOYEE EMPLOYEE + ONE CHILD EMPLOYEE + SPOUSE EMPLOYEE + CHILDREN EMPLOYEE + FAMILY 10 PAY $_ (CIRCLE ONE) 12 PAY 19 PAY 24 PAY WAIVE HEALTH INSURANCE DELTA DENTAL Dental Care (CHECK ONE) (check one) DELTA CARE (DHMO) DELTA DENTAL PPO LOW DELTA DENTAL PPO HIGH WAIVE DENTAL INSURANCE EMPLOYEE EMPLOYEE + CHILD EMPLOYEE + SPOUSE EMPLOYEE + FAMILY WAIVE DENTAL INSURANCE 10 PAY $ (CIRCLE ONE) 12 PAY 19 PAY 24 PAY METLIFE Short Term Income Protection (STIP) (CHECK ONE) OPTION 1 (14-day Waiting Period) OPTION 2 (28-day Waiting Period) OPTION 3 (42-day Waiting Period) WAIVE STIP 10 PAY $_ (Approximately) (CIRCLE ONE) 12 PAY 19 PAY 24 PAY NAVIA BENEFIT SOLUTIONS Flexible Spending (FSA) HEALTH CARE ANNUALLY $_ DAY CARE ANNUALLY $_ 10 PAY 10 PAY $_ $_ (CIRCLE ONE) 12 PAY 19 PAY 24 PAY (CIRCLE ONE) 12 PAY 19 PAY 24 PAY WAIVE FSA MINNESOTA LIFE Optional Group Life Insurance (Full-time Employees Only) CHECK ONE 1 X Salary 2 x Salary 3 x Salary 4 x Salary WAIVE Optional Life NOT ELIGIBLE CHECK ONE EMPLOYEE EMPLOYEE + CHILD(REN) EMPLOYEE + SPOUSE EMPLOYEE + FAMILY MY SPOUSE/PARENT IS EMPLOYED WITH HENRICO COUNTY: General Government OR Schools Full-time OR Part-Time Name of Spouse/Parent: Location: Spouse SS# I authorize the Payroll Office to deduct the additional amount(s) from my pay so that my benefits may become effective as I have requested. I may make a benefit change within 31 days of my employment and within 60 days of any other qualifying event. According to IRS federal code (Section 125, pretax option), benefit changes must be consistent with the qualifying event. Changes made by HCPS and its employees are subject to review for compliance. Employee s Signature Please check and initial to indicate you have read the reverse side. Date January 2017

48 BENEFITS DEDUCTION AUTHORIZATION FORM Pre-Tax payment plan Payroll deductions for health and/or dental premiums will be taken from your pay before taxes are taken out. This pre-tax arrangement allowed by the IRS reduces your salary for tax purposes by the amount of your health and/or dental premium deductions, making your take-home pay greater than if you were to pay for the same benefits on a post-tax basis. Benefit Elections New employees make benefit elections at their initial employment date. Current employees may change their benefit elections during annual open enrollment periods. Elections remain effective for each plan year (January 1 through December 31). Mid-year benefit election changes may be made within 60 days following a qualifying event or status change. Qualifying Events and Status Changes (This is a list of the most common events and changes. Contact the HCPS Benefits Office for a complete list.) Marriage Divorce Death of a spouse or dependent Birth, adoption, or placement for adoption Change in employment status of employee, spouse or dependent child Change in spouse s or dependent child s employer-provided benefit plan Spouse or dependent s employer s Open Enrollment Child reaching age when he/she can no longer be covered by plan (age 26) Information Sources The Anthem benefit brochure and the Summary of Benefits and Coverage for the health plans are available for review at the Henrico County Public Schools website, http :// henricoschools.us/benefits. You may also wish to review options in the Health Insurance Marketplace by visiting ALL EMPLOYEES ARE ELIGIBLE TO PARTICIPATE IN THE FOLLOWING: VALIC Tax Sheltered Annuity (403b Plan) Henrico Federal Credit Union Direct Deposit, Free Checking, Savings, and many other features January 2017

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50 HPS Henrico County Public Schools Flexible Spending Arrangement Enrollment Form Plan Year: 1/1/ /31/2017 Last Day to Submit Claims: 3/31/2018 Employee Information Please write legibly to ensure proper enrollment Last Name, First Name SSN / Employee ID # Home Address (Street, City, State, Zip Code) Address Date of Birth (MM/DD/YYYY) Phone Number Effective Date (If outside open enrollment) Benefit Elections Section 125 Benefit Yes/No Annual Election # of Paychecks Paycheck Deduction Health Care FSA Maximum of $2, per plan year Yes No $ $ Day Care FSA Maximum of $5, per plan year (or $2,500 if you re married and filing taxes separately) Yes No $ $ Debit Card & Direct Deposit Signature This election form will remain in effect and cannot be revoked or changed during the plan year unless the revocation and new election are on account of and consistent with federal regulations. I understand that Health FSA reimbursements will be available only for qualifying medical care expenses for myself, spouse, and dependents. I also understand that Day Care reimbursements will be available only for qualifying day care expenses. I agree to notify the Employer if I have reason to believe that any expense for which I have obtained reimbursement is not a qualifying expense. I also agree to indemnify and reimburse the Employer on demand for any liability it may incur for failure to withhold federal, state or local income tax or Social Security tax from any reimbursement I receive of a non-qualifying expense, up to the amount of additional tax actually owed by me. I understand the benefits and I have read the reverse page. I hereby authorize and direct my employer to reduce my salary by the amount necessary to pay for the benefit(s) as shown above for the plan year indicated above. YES, the above benefits have been explained to me and I elect to participate as indicated NO, the above benefits have been explained to me and I decline participation Employee Signature Date X Completed Enrollment Forms must be returned to: Health Benefits Office Please see the reverse side for important information regarding the above benefits 8/29/2016

51 Additional Information Health Care Flexible Spending Arrangement ( Health Care FSA ) Reimbursement will only be available for qualifying medical care expenses as set forth in the Plan Document and Section 213 of the Internal Revenue Code. It is your responsibility to check the eligibility of an expense prior to enrollment. Group Medical Plan Premiums cannot be reimbursed through the Health Care FSA and will be deducted pre-tax through the Premium Conversion Plan. Therefore, do not include the cost of premiums in your FSA annual election amount. Day Care Flexible Spending Arrangement ( Day Care FSA ) Reimbursement will be available only for qualifying day care expenses as described in the Internal Revenue Code Section 129, the Plan document and the Summary Plan Description. Participation in a Day Care FSA will require you to complete tax form 2441 when filing federal taxes.. If you or your spouse is a full-time student, please consult IRS Publication 503. If the Plan Year is less than twelve (12) months, the plan limit may be prorated to be less than the $5,000 calendar year limit mandated by the IRS. Use-It or Lose-It You must claim all elected funds by the end of the run-out period. After the run-out period is complete, unused Day Care FSA balances will be forfeited; this is referred to as the Use-it or Lose-it rule. Unused Health Care FSA balances up to $500 will be rolled over to the subsequent plan year. Any Health Care FSA funds in excess of $500 will be forfeited. Claim Runout Period The claim runout period allows you to submit claims after the end of the plan year. Claims received after this period will be denied. Lost Checks and Reissues Lost or stale dated FSA checks can be reissued 10 business days after the original check date. There is a $25.00 check reissue fee. The check reissue request will require at least one business day to process. Any fees associated with presenting a canceled check will be deducted from your FSA as well as the face value of the check. Deductions FSA deductions will be deducted from your paycheck evenly throughout the plan year. You must indicate an annual election and a per paycheck deduction on your enrollment form. If you enroll in the plan after open enrollment then please divide your annual election by the remaining deductions in the plan year. Change in Status All elections set forth are considered irrevocable for the entire plan year unless there is a qualifying change in status. Please consult the plan document for a list of qualifying events. In the event of a change in status the change in election must be necessitated by and consistent with the change in status and the change must be acceptable under IRS Regulations. Eligibility Full-time and part-time employees working 20 hours per week are eligible to participate in the Plan Expenses must be incurred during the plan year and while you are an active participant in the plan. Any expense incurred prior to your effective date or after your termination date cannot be reimbursed. Electronic Disclosure Notice By providing your address you consent to receive communications from Navia, agents, and subcontractors regarding the Plan. If you no longer wish to receive information electronically, you may withdraw consent at any time at no cost. To withdraw consent, please contact Navia. You have a right to receive a paper version of an electronically furnished document at no cost. To access documents you must have Adobe Reader. A link to download this software will be provided with all electronic documents provided.

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55 Income Protection Program Enrollment Form Personal Information: Name: Social Security Number: Short Term Income Protection (STIP) through MetLife is an optional benefit available to full-time and part-time employees who work a minimum of 20 hours per week. Full-time employees who are VRS Plan 1 or Plan 2 members and part-time employees may select or change options at Open Enrollment each year. Pre-existing conditions may apply. STIP premiums are paid by the Employee on an after-tax basis. (See reverse side for information on the Long Term Income Protection (LTIP) program for these full-time employees.) Full-time employees who are VRS Hybrid members may enroll with MetLife STIP for a period of 12 months starting with date of hire. Any MetLife STIP coverage you may select today as a new hire will end after 12 months. No STIP changes are allowed at Open Enrollment. Short Term Disability (STD) and Long Term Disability (LTD) coverage with The Standard will automatically become effective after meeting the 12 month eligibility period after your date of hire for non-work related disabilities. The Standard STD and LTD premiums are Employer-paid by HCPS at no cost to the Employee. Work related disabilities for all are processed through Worker s Comp as they occur. Short Term Income Protection ( STIP) through MetLife Please check ONE box below and sign at the bottom. Option 1: 14 Calendar Day Waiting Period for Benefits to begin Option 2: 28 Calendar Day Waiting Period for Bene fits to begin Option 3: 42 Calendar Day Waiting Period for Benefits to begin Option 4: I waive the options above. I authorize my employer to deduct premi ums for the option checked above from my paycheck on a post - tax basis or, I have selected the Waive option. Signature Date

56 Long Term Income Protection (LTIP) Program For VRS Plan 1 or Plan 2 Members, only LTIP coverage becomes effective once you have been employed full-time for 6 months. You are covered at 60% for up to $50,000 in annual salary, beginning with the 91 st day of disability. To enroll for Additional LTIP Coverage to protect salary above $50,000: Visit the HCPS website and download the LTIP Enrollment form at: Important Eligibility Information: If your LTIP Enrollment Form is received within 31 days from the later of: 1) the date you completed 6 months of service, or 2) the date your annual earnings exceed $50,000, then you will be enrolled for additional coverage without Evidence of Insurability. Return your completed LTIP Enrollment Form to: Henrico County Public Schools Health Benefits Office P. O. Box Henrico, VA If your LTIP Enrollment Form is received more than 31 days from the later of: 1) the date you completed 6 months of service, or 2) the date your annual earnings exceed $50,000, then you must submit a Statement of Health form, also found at the HCPS website ( to MetLife for approval. If your enrollment for additional coverage is approved, your corresponding payroll deductions will be initiated. Or Please call the Health Benefits Office at if you have questions. January 2017

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