New Employee Benefits Package CERTIFIED EMPLOYEES

Transcription

1 Hopkins County Schools New Employee Benefits Package CERTIFIED EMPLOYEES In this packet, you will find the following insurance forms. Please print this package and complete the forms listed below. Bring the completed forms with you to your appointment with Human Resources to complete the hiring process. KEHP Health Insurance Enrollment Application o This Benefits Selection Guide is provided online to help you choose your health plan. o If you choose a plan that includes a flexible spending account, please view FSA Sample Eligible Expenses. o If you choose Living Well PPO or Living Well CDHP, you must complete the Health Assessment online ( when you receive your ID card in the mail. o You will need to register and create your user ID and password. If you have questions, call the number on the back of your insurance card. If you do not take the Health Assessment, you will not be able to choose one of these plans for next year. 5 Star Life Insurance o The Board of Education provides a $20,000 life insurance policy to employees. You have the option to choose extra life insurance that is portable when you leave or retire. If you are interested, please contact Kay Little at Nationwide Life Insurance o The state provides a $20,000 Nationwide Life Insurance policy to employees. o Please complete both the Enrollment/Change/Termination Form and the Nationwide Employee Benefits Group Life and Accidental Death Designation of Beneficiary Form. For more information, view our Benefits Frequently Asked Questions page.

2 Kentucky Employees Health Plan Department of Employee Insurance kehp.ky.gov ACTIVE EMPLOYEE HEALTH INSURANCE ENROLLMENT APPLICATION Section 1: To Be Completed by IC/HRG KHRIS Personnel Number Organizational Unit # Company Name Company # Home County Code Reason for Application New Hire Open Enrollment New Group Prior Company Name Prior Company # Coverage Effective Date Date of Hire Cost Center # Section 2: Demographic Information Employee s SSN Name (Last, First, MI) Date of Birth Street Address Primary Phone Number Work Address City, State, ZIP Home County Secondary Phone Number Home Address Sex Male Married Yes Female No Within the past 6 months, have you, or a spouse or dependent(s) age 18 and over, to be covered under your insurance plan, used tobacco regularly? Yes No Section 3: Spouse/Dependent Information (Complete Section 3 only if you are electing parent plus, couple or family coverage) Spouse s Information Social Security Number Name (Last, First, MI) Date of Birth Sex Male Female Cross-Reference Payment Option ONLY (LRP, JRP not eligible) 1. Do you and your spouse utilize the cross-reference payment option? [two KEHP members, married with child(ren)]? Yes 2. Within the past 6 months, have you, the spouse, used tobacco regularly? Yes No 3. Date of Hire/Retirement 4. Organizational Unit # 5. Company # Dependent(s) Information If you need additional room for dependents, add them to another page and include as part of the application. Child 1 Social Security Number Name (Last, First, MI) Date of Birth Male Female Disabled Dep. Child 2 Social Security Number Name (Last, First, MI) Date of Birth Male Female Disabled Dep. Child 3 Social Security Number Name (Last, First, MI) Date of Birth Male Female Disabled Dep. Section 4: Plan Options LivingWell CDHP I AGREE to the LivingWell Promise LivingWell PPO I AGREE to the LivingWell Promise If you do NOT AGREE to the LivingWell Promise, or if you failed to fulfill your LivingWell Promise in 2015, you must select a Standard plan option below Standard PPO Standard CDHP Section 5: Coverage Levels Single (self only) Parent Plus (self and child(ren)) Couple (self and spouse) Family (self, spouse and child(ren)) Section 6: Waiving Health Insurance (no health insurance) If you waive your health insurance AND you are eligible and can declare that you have other group health plan coverage, you will receive $175 per month up to $2,100 annually into a Health Reimbursement Arrangement (HRA).This is employer-funded; you do not contribute any money. Waiver (General Purpose) HRA-with $ By choosing a Waiver HRA and checking this box, I declare that I have other group health plan coverage that provides minimum value. A group health plan refers to coverage provided by an employer, an employer organization, or a union. A group health plan does not include individual policies purchased through kynect or governmental plans such as TRICARE, Medicare, or Medicaid. A group health plan that provides minimum value means the plan pays at least 60% of the total allowed cost of covered benefits/services and participants or members in the plan are required to pay no more than 40% of the total allowed cost of covered benefits/services. Waiver Dental/Vision ONLY HRA-with $ You may choose this option if you are not eligible for the Waiver HRA. May be used for dental and vision only. No HRA-without $ 2016 Active Application / Page 1 of 4

3 Plan Year 2016 TOBACCO USE DECLARATION Employee s SSN Employee s Name The Commonwealth of Kentucky is committed to fostering and promoting wellness and health in the workforce. As a part of the KEHP wellness program, KEHP provides a monthly discount in premium contribution rates for non-tobacco users. You are eligible for the nontobacco user premium contribution rates provided you certify that you or any other person to be covered under your plan has not regularly used tobacco within the past six months. TOBACCO USE INFORMATION Check the applicable box below: Within the past six months, have you, or a spouse or dependent to be covered under your insurance plan, used tobacco regularly? Yes No NOTE: Regularly means tobacco has been used four or more times per week on average excluding religious or ceremonial uses. NOTE: Tobacco means all tobacco products including, but not limited to, cigarettes, pipes, chewing tobacco, snuff, dip, and any other tobacco products regardless of the frequency or method of use. NOTE: Dependent means, for the purpose of the Tobacco Use Declaration, only those dependents who are 18 years of age or older. By submitting this form, I certify the following: 1. I have truthfully checked the Yes or No box above that accurately reflects the use of tobacco products in the past six months regarding myself and persons to be covered as a spouse or dependent under my insurance plan. 2. I understand that the tobacco-user premium contribution rates will apply beginning January 1, 2016 if I answered Yes to the question above. 3. I understand that it is my responsibility to notify KEHP of any changes in my tobacco-use or that of my spouse or a dependent covered under my insurance plan, including notification to KEHP if all tobacco users become ineligible for coverage or are otherwise terminated during the plan year. Notification shall be made by completing a Tobacco Use Change Form. 4. I understand that if I or a spouse or dependent to be covered under my insurance plan currently use tobacco products and stop using tobacco products during the plan year, I will be eligible for the discount non-tobacco premium contribution rates on the first day of the month following the signature date on the Tobacco Use Change Form certifying that neither I nor my spouse/dependent(s) regularly used tobacco products during the six months prior to completion of the Tobacco Use Change Form. 5. I understand that if I answered No to the question above and either I or a spouse or dependent covered under my insurance plan become a regular tobacco user at any time, I must notify KEHP and my contribution rates will be adjusted to the tobacco-user premium contribution rates on the first day of the month following the signature date on the Tobacco Use Change Form. 6. I understand that this Tobacco Use Declaration is a part of my KEHP application for health insurance coverage. Any person who knowingly, and with the intent to defraud, files an application for insurance containing any materially false information, or who conceals, for the purpose of misleading, information concerning any fact material to the application, commits a fraudulent insurance act which is a crime. 7. I understand that if I fail to complete this Declaration truthfully, KEHP may adjust my contribution rates retroactively to apply the applicable higher tobacco-user premium contribution rates. Upon written notification, I will pay to KEHP the difference between the tobacco-user and the non-tobacco user premium contribution rates for the period for which I falsely certified eligibility for the non-tobacco user premium contribution rates. 8. The KEHP offers monthly discounted premium contribution rates to non-tobacco users as a part of its wellness program. Each KEHP member has at least one opportunity per plan year to qualify for the discount. KEHP is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact the Department of Employee Insurance at (888) or (502) and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status. Review the Authorization and Certification Information Authorization and Certification for elections made by the planholder for health insurance coverage through the Kentucky Employees Health Plan (KEHP or Plan), administered by the Department of Employee Insurance (DEI). For the purposes of this Authorization and Certification, FSA refers to a Healthcare Flexible Spending Account and a Dependent Care Flexible Spending Account, collectively. A Healthcare Flexible Spending Account will be referred to as a Healthcare FSA. A Dependent Care Flexible Spending Account will be referred to as a Dependent Care FSA. My signature on this application for health insurance creates a legal and binding contract. By affixing my signature, I understand and agree that: If I am electing a KEHP plan option or enrolling in an FSA during open enrollment, the plan and FSA will be effective January 1 of the following plan year. If I am a new employee or a newly eligible employee electing a KEHP plan option or enrolling in an FSA outside of open enrollment, 2016 Active Application/Page 2 of 4

4 Plan Year 2016 Employee s SSN Employee s Name the plan and/or FSA will be effective the first day of the second month after a new employee or newly eligible employee is eligible to enroll in the health plan or an FSA. I have read and understand the 2016 KEHP Benefits Selection Guide (BSG). Plan rules and limitations are contained in the KEHP Summary Plan Descriptions (SPD) or Medical Benefit Booklets (MBB) and the Summary of Benefits and Coverage (SBC). All KEHP benefits for my eligible dependents and me will be provided in accordance with the limitations in the SPDs, MBBs, BSG, and SBCs. I will abide by all terms and conditions governing participation in an FSA and as set forth in the SPD, and by all terms and conditions governing membership and receipt of services from the plan in which I have enrolled and as set forth in the SPD and MBB. In the event of a conflict between the terms of coverage stated in the SPDs, the MBBs, the BSG, and the SBCs, the terms of coverage stated in the SPDs and/or MBBs will govern. KEHP uses third parties, including Anthem, CVS Caremark, and WageWorks to provide certain administrative functions. KEHP may communicate with me directly or through these third parties about my coverage, my benefits, or health-related products or services provided by or included in KEHP s plan of benefits. If my spouse and I elect the cross-reference payment option, we are planholders with family coverage, and upon a loss of eligibility by either spouse, the remaining planholder will default to a parent plus coverage level. The cross-reference payment option ceases upon loss of eligibility or employment by either spouse/planholder. I certify that each enrolled dependent meets KEHP s dependent eligibility requirements as set forth in the SPD and/or the MBB. DEI may require supporting documentation to verify the eligibility of any dependent enrolled or requesting to be enrolled in the Plan. The elections indicated by this application may not be changed or cancelled during the plan year without a permitted Qualifying Event. Enrollment in an FSA is voluntary. I authorize my employer to deduct from my earnings the amount required to cover my employee contribution to the FSA I have selected, including any arrears I may owe. I authorize payment of my employee contributions to be made on a pre-tax basis. I authorize my employer to deduct from my earnings the amount required to cover my employee share of the premium contribution for the plan option I have selected, including any arrears I may owe. I authorize payment of my employee premium contributions to be made on a pre-tax basis unless I sign a Post-Tax Request Form. Any payment submitted to KEHP that I intend to be used to fund my FSA and any premium payment submitted to KEHP that I intend to be used to pay for my health insurance premium contributions may first be used to pay other priority debts that may be due and owing such as taxes and child support. If I choose a Dependent Care FSA, I am eligible to seek reimbursement, as authorized by 26 U.S.C. Sections 21 and 129, for dependent care expenses. The Dependent Care FSA may only reimburse eligible dependent care expenses that are incurred during the applicable coverage period. Any unused amount remaining in my Healthcare FSA at the end of the calendar year will be carried forward to the next calendar year, up to a maximum carry over amount of $ WageWorks will administer FSAs and HRAs for the 2016 plan year and will issue to me a WageWorks Healthcare Card for the payment of Healthcare FSA and HRA expenses. My WageWorks Healthcare Card will be suspended if the required claim verification is not sent to WageWorks within ninety (90) days after the card swipe. I agree to follow all rules and guidelines established by the Plan concerning the WageWorks Healthcare Card. The Plan reserves the right to deny access to the card, require repayment, deduct/withhold from my paycheck, and offset my Healthcare FSA or HRA if I fail to properly verify a claim. If I elect to waive KEHP health insurance coverage, with or without a Waiver Health Reimbursement Arrangement (HRA), I am doing so voluntarily. If your employer participates in the Waiver HRA program, there are two options available: the Waiver General Purpose HRA and the Waiver Dental/Vision Only HRA. I understand that I will be eligible for the Waiver General Purpose HRA only if I have other group health plan coverage. If I elect a Waiver General Purpose HRA, I declare that I am enrolled in another group health plan that provides minimum value. A group health plan refers to coverage provided by an employer, an employer organization, or a union. A group health plan does not include individual policies purchased through kynect or governmental plans such as TRICARE, Medicare, or Medicaid. A group health plan that provides minimum value means the plan pays at least 60% of the total allowed cost of covered benefits/services and participants or members in the plan are required to pay no more than 40% of the total allowed cost of covered benefits/services. If I elect a Waiver General Purpose HRA and I cease to be covered under another group health plan that provides minimum value, I will notify KEHP within 35 days of the date that the other group health plan coverage ceased. In this event, coverage under the Waiver General Purpose HRA will be terminated and I may elect a KEHP health insurance plan option or the Waiver Dental/Vision Only HRA. I am permitted to permanently opt out of and waive future reimbursements from the Waiver General Purpose HRA at least annually at open enrollment. Any funds remaining in a Waiver HRA after termination may be used to reimburse the employee for eligible expenses incurred prior to termination of the Waiver HRA. Upon termination of employment, the remaining amounts in a Waiver HRA are forfeited except that I may be reimbursed for any eligible medical expenses incurred prior to the last day of the last pay period worked, provided that I file a claim by March 31 following the close of the plan year in which the expense was incurred Active Application/Page 3 of 4

5 Plan Year 2016 Employee s SSN Employee s Name KEHP provides plan options that, under the Affordable Care Act, constitute minimum essential coverage that is affordable and provides a minimum value. As such, by receiving an offer of coverage through my employer, I am not eligible for a health insurance premium tax credit if purchasing insurance through kynect. In addition, if I decline coverage for my spouse or dependent, my spouse or dependent will not be eligible for a health insurance premium tax credit if purchasing insurance through kynect. An HRA and/or Healthcare FSA may only reimburse me for medical expenses, as authorized by 26 U.S.C. Sections 105(b) and 213(d), that are incurred during the applicable coverage period. The Waiver Dental/Vision Only HRA may only reimburse me for eligible dental and vision expenses. Pursuant to federal law, the cost of over-the-counter medicines (other than insulin and those prescribed by a doctor) may not be reimbursed through my HRA or Healthcare FSA. I have a 90-day run-out period (until March 31) for reimbursement of eligible FSA and HRA expenses incurred during my period of coverage. Any unused amount remaining in my HRA at the end of the plan year may be carried forward to the next plan year provided I am eligible to elect an HRA. I must elect the same type of HRA in a subsequent plan year for the funds to carry over. The four KEHP plan options and the Waiver General Purpose HRA must pay primary to Medicare. The Waiver Dental/Vision Only HRA pays secondary to Medicare. The KEHP offers discounted premium contribution rates to non-tobacco users as a part of its wellness program. If either I or a spouse or dependent to be covered under my insurance plan have used tobacco regularly within the past six months, I will not qualify for the discounted employee premium contribution rates. Each KEHP member has at least one opportunity per plan year to qualify for the discount. KEHP is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees/retirees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact the Department of Employee Insurance at or and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status. KEHP does not collect or retain personal health or medical information through its wellness program; however, KEHP may receive aggregate information that does not identify any individual in order to design and offer health programs aimed at improving the health of KEHP members. If I have chosen one of the KEHP LivingWell plan options, I agree to fulfill the KEHP LivingWell Promise by completing (1) my online HumanaVitality Health Assessment; OR (2) a VitalityCheck (biometric screening). If I am choosing a LivingWell plan option during open enrollment, I will complete the Health Assessment OR a VitalityCheck (biometric screening) from January 1, 2016 through May 1, If I am a new employee and I choose a LivingWell plan option outside of open enrollment, I will complete the Health Assessment OR VitalityCheck (biometric screening) within 90 days of my coverage effective date. I have rights under HIPAA regarding the protection of my health information. KEHP will comply with the HIPAA Privacy and Security rules, and uses and disclosures of my protected health information will be in accordance with federal law. KEHP may use and disclose such information to business associates or other third parties only in accordance with KEHP s Notice of Privacy Practices available at kehp.ky.gov. Any person who knowingly, and with the intent to defraud, files an application for insurance containing any materially false information (including a forged signature or incorrect signature date), or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act which is a crime. I can be held responsible for any fraudulent act that I could have prevented while acting within my duties related to the KEHP, and it may be used to reduce or deny a claim or to terminate my coverage. I have fully read the materials provided to me. My signature on this application certifies that all information provided during this enrollment opportunity is correct to the best of my knowledge. Exceptions may apply to employees of certain employers participating in KEHP and to KTRS, KRS, LRP, and JRP retirees. Please refer to the participation rules of your employer or retirement system for further information. PLEASE SUBMIT THIS APPLICATION TO YOUR COMPANY IC/HRG Employee Signature Date Spouse Signature REQUIRED if electing the cross-reference payment option Date IC/HRG Signature Date Spouse s IC/HRG Signature REQUIRED if electing the cross-reference payment option Date 2016 Active Application/Page 4 of 4

6 Attachments: Employer Name Employer Tax ID # Last Name First Name M.I. D.O.B. SSN Male Female Height ft in Weight lbs Home Address: Street Line 1 Street Line 2 Underwritten by 5Star Life Insurance Company (a Baton Rouge, Louisiana Company) Admin Offices: 909 North Washington Street, Alexandria, VA Agent use only Agent# INTERNAL USE ONLY: (Statement of Health must be completed.) 5Star Multiple Employer Trust Group Life Insurance Enrollment Form Use black or blue ink and print using all upper case letters. New Enrollee Late Enrollee Name Change Coverage Change Beneficiary Change Initials: Employer Information Employee/Applicant Information / / Month Day Year City State Zip Daytime Phone Number Full-Time Employment Date / / Coverage Effective Date / / Month Day Year Employee Insurance Coverage Basic Group Basic Group Life Amount $, AD&D Amount $, Amounts requiring Evidence of Insurability are subject to Statement of Health. Voluntary Group Voluntary Life Amount $, AD&D Amount $, Amounts requiring Evidence of Insurability are subject to Statement of Health. Voluntary Earnings $, (If coverage is earnings based) Premium Amount $. Voluntary/Optional Dependent Insurance Coverage Month Day Year Spouse Child 1 Child 2 Child 3 Child 4 GMT200ENR-R106 10/07

7 Beneficiary Information I designate my beneficiary(ies) to receive benefits as indicated below. The employee is the beneficiary for all dependent coverages. If more than one beneficiary is named, the beneficiaries shall share equally unless otherwise stated below. Primary Name Address Relationship SSN DOB % Secondary Name Address Relationship SSN DOB % Statement of Health (To be completed only for amounts of coverage requiring evidence of insurability) Answer each question and initial in the box to acknowledge you ve read and understood each question. Circle the specific condition and give full details to any yes answers in the chart below. Initial Here I. In the last 10 years, has the Applicant under this application for coverage: A. Had a life or health insurance application declined or rated?... B. Had any known indication of or been treated by a physician or consulted with a health advisor for any of the following: High blood pressure, high cholesterol, chest pain, heart attack, vascular disease (plaque in arteries), or other heart or blood vessel disorder; cancer or blood disorder; stroke, seizures, progressive neuropathy, or other nervous system disease; shortness of breath, asthma, chronic obstructive pulmonary disease (COPD), or other respiratory tract disorder; hepatitis, pancreatitis, colitis, or other disorder of the stomach, liver, pancreas, intestines, or digestive system; depression, schizophrenia, or other mental condition; alcoholism or alcohol abuse; diabetes, thyroid disease, pituitary disorder, or other gland disorder; disorder of the kidney, bladder, urinary tract, genital tract, or reproductive system; or any other significant medical disorders?... C. Used marijuana, cocaine, heroin, barbiturates, hallucinogens, amphetamines, or any illicit drug except by physician prescription?... II. Has the Applicant been diagnosed by a physician or tested positive for Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS), or any AIDS-related condition?... III. List each prescribed medication taken regularly or frequently by Applicant: IV. In the past 5 years, has the Applicant for this coverage been admitted or confined to any hospital or medical treatment facility?... Yes No For any Yes answers above, please complete the following. Attach additional details on an 8.5 x 11 piece of paper and submit with this enrollment form. Ques Condition, injury, findings Date Date of Name & Address of Hospital No. Name of examination or prescription (Mo/Yr) Recovery or Attending Physician Conditions Relating to This Enrollment Form Group Eligibility: I am eligible to apply for this group insurance as a full time employee of an employer under the Group Policy issued to the Trustee, America s 5Star Multiple Employer Trust by 5Star Life Insurance Company. Agreement: I, as employee, have the appropriate knowledge to answer the statement of health questions for my spouse. I represent that all statements and answers in this enrollment form are complete, true and correctly recorded to the best of my knowledge and belief. I agree that 1) upon approval of this enrollment form by 5Star Life Insurance Company, it and the Certificate of Insurance Coverage issued to me will describe the benefits and terms of coverage provided under the Master Group Policy; 2) coverage applied for will not become effective until approved by 5Star Life Insurance Company and is subject to the health relating to each person to be covered being as described in this enrollment form, and upon receipt of the full first contribution, in which case the coverage shall take effect as of the effective date as shown in the Certificate of Insurance Coverage; 3) if within 60 days of receipt of all required documentation this enrollment form is not approved, I will be notified that it will become void and any contributions paid will be refunded. Note: Within the time limits prescribed by the law of the state where you live, no benefits will be paid and contributions will be refunded if the covered person commits suicide while sane or insane. Refer to your Certificate of Insurance Coverage for details. Authorization: I hereby authorize payroll deduction from my earnings of the required contribution, if any, toward the cost of such insurance for myself and my family members. Authorization may be revoked by me at any time by written notice to my employer. I understand that if my employment is terminated, upon re-employment, insurance will not become effective until I apply again for insurance in accordance with the terms of the Group Policy. I hereby authorize any licensed physician; medical practitioner; hospital; clinic or other medical facility; insurance company; employer; Medical Information Bureau; Motor Vehicle Administration or other organization; or persons that have any records or knowledge of me or my physical or mental health condition to give 5Star Life Insurance Company, its authorized representative, and its reinsurers any such information. I understand that this information will be used to determine my eligibility for coverage and that I may revoke this authorization and enrollment form at any time by providing written notice. A photocopy of this authorization shall be as valid as the original. This authorization shall be valid for 24 months from the date below. I acknowledge that I, or my authorized representative is entitled to receive a copy of this authorization. Signature must be personal. Sign Here Employee s Signature Date Signed at (City, State) NOTE: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information may be guilty of a crime and may be subject to fines and confinement to prison. Not available in all states Admin Office: 909 N. Washington St, Alexandria, VA /07

8 2015 Nationwide Life Commonwealth of Kentucky Insurance Company Employee Group Life Insurance Program Home Office: Columbus, Ohio Group Insurance Contract: BE 0002 SSN Location Name (Specify name or Agency, School Board or Health Dept.) Name (Last, First, MI) Location Number Birth date Address (Street Name/Number) Annual Salary Hire Date Gender Male Female (City, County, State, Zip) Work Number Home Number Termination: Date Employment Ends Date Life Insurance Terminates Reason: Resigned Retired LWOP Death Military Leave Other Reinstate Coverage: Date Returned to Work Date Insurance Effective Reason: Rehired FMLA LWOP Death Military Leave Other Transfer or Summer Transfer (To be completed by the NEW company) Prior Company Number Last Day Worked at Prior Company Coverage End Date at Prior Company New Company Number Date Hired at New Company Coverage Begin Date at New Company A. Basic Life and Accidental Death and Dismemberment (AD&D) Insurance Eligible employees are insured at no cost to the employee for Basic Life and AD&D Insurance All Eligible Employees $20,000 Cost: (employer paid) B. Optional Life and Accidental Death and Dismemberment (AD&D) Insurance (Select One Plan) I wish to enroll* in, change* to, or terminate* the optional insurance plan checked below: (Select one plan only) Monthly Contribution Age Band Rate per $1,000 Under 40 $ $ and over $0.98 Plan 1 $5,000 Plan 2 $10,000 Plan 3 (NEW) $25,000 Plan 4 (NEW) $50,000 Plan 5 1X Annual Salary** Plan 6 2X Annual Salary** *Evidence of insurability may be required depending on the circumstances and/or for insurance over $150, 000. **Under Plans 5 and 6, insurance amounts will be rounded to the nearest multiple of $1,000. Amounts of insurance will increase with an earnings change. C. Dependent Life Insurance (Select One Plan) Please enroll* my dependents in, change*my present plan to, or terminate* the plan checked below: (Select one plan only) Plan A Plan B Plan C Plan D Plan E Spouse** $10,000 $5,000 $5,000 $10, Dependent Children to 6 mos $2,500 $1, $2,500 Dependent Children 6 mos to 18 yrs*** $5,000 $3, $5,000 Monthly Contribution $11.46 $6.20 $2.62 $9.14 $3.78 *Evidence of insurability may be required depending on circumstances ** Spouse means a person to whom you are legally married *** 18 and older if attending an educational institution and relying on the employee for financial support D. Waiver of Optional Life and Dependents Coverage I certify that I have been given the opportunity to enroll myself and my eligible dependents in the above coverage. I have declined the Optional and/or Dependents Life coverage and understand that it will be necessary for me and my dependents to furnish evidence of insurability if I desire any of the above coverage in the future (other than during an open enrollment period or other exception detailed in the certificate booklet). E. Fraud Warning: Any Person who knowingly and with intent to injure, defraud, or deceive an insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing an insurance application or a statement of claim for payment of a loss of benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. F. Employee Signature and Date (Required) I, the undersigned, certify that I have read the completed enrollment/change/termination form and agree that all answers in this form are true and complete to the best of my knowledge and belief. I hereby authorize my employer to deduct from my paycheck or earnings the amount required to cover my share of the coverage I have selected. Employee Signature IC/HRG Signature Date Date Send Copy to your Insurance Coordinator

9 2015 Within thirty-five (35) days from their date of hire, new employees may enroll in group life insurance online by using the KHRIS Employee Self Service Center (ESS). Instructions Print all information using black or blue ink (if submitting a paper form.) Complete location name and number. Annual earnings are required when selecting Optional Plan 5 or 6. Select only one plan for Optional Term Life coverage. Select only one plan for Dependent Term Life coverage. Employee must provide evidence of insurability for coverage over $150,000. This must be approved by the insurance carrier before coverage can be initiated. Spouse is defined as a person to whom you are legally married. Child 18 or older can remain covered providing the child is a full-time student and relying on the employee for financial support. Employee signature and date is required (if submitting a paper form.) Insurance Coordinator should verify all information in ESS, or sign and date form. Description of Qualifying Event should be completed by the Insurance Coordinator. For example: Marriage only. Date of Qualifying Event should be listed as the last day employee worked or official date of termination, not when coverage will end. For Board of Education employees with salary based plans, the new contract year salary will be effective 11/1 of each year. For Health Department and Quasi agency employees with salary based plans, please verify that your HR Administrator is maintaining your current salary. Premium rates are effective as of January 1, Rates may change as the insured enters a higher age category or if the plan experience requires a change for all insured.