EMPLOYEE INFORMATION BENEFIT ENROLLMENT FORM Name: Address: City: State: Zip: Phone # SSN#: G-ID#: Birth : Gender: Male Female Primary Care Physician: PCP Code: BENEFIT ELECTIONS (see Medical Rates Sheet for monthly deduction amounts) HEALTH CHOICE (If Applicable) HMO Priority Health HealthbyChoice Achievements HMO HMO Health Alliance Plan (HAP) Achieve HMO HMO Blue Care Network (BCN) Healthy Blue Living Blue Cross Blue Shield (BCBSM) Community Blue A. Blue Cross Blue Shield (BCBSM) Community Blue B Waive Coverage (you must complete the Waiver of Coverage Form) VISION CHOICE (If Applicable) BCBSM Vision Davis Vision I DO NOT elect vision coverage DENTAL (If Applicable) Delta Dental I DO NOT elect dental coverage I authorize Oakland University to make a pre-tax deduction from my paycheck each pay period which equals, and is used for, my share of the premium coverage I have selected above. Signature: :
SPOUSE, OTHER ELIGIBLE ADULT, DEPENDENT INFORMATION Spouse/Other Eligible Adult Information DOB: Gender: Male Female Relationship: Spouse Other Eligible Adult Dependent Information (List ALL dependents being enrolled in your plan) Address (If different from Employee): City State Zip:
New Hire Medical Insurance Waiver of Coverage Form EMPLOYEE INFORMATION Name: _ G-ID#: I hereby waive, for myself and each of my dependents, all eligibility for and/or participation in Oakland University s group medical insurance plan ( Plan ). I understand and acknowledge that: A. Because I am employed by Oakland University, my dependents and I were eligible for and had been offered the opportunity to participate in the Plan. B. The Plan will not pay any medical expenses for me or any of my dependents while this waiver is in effect unless we are covered as eligible dependents of another Oakland University employee who is participating in the Plan. c C. This waiver will remain in effect until I enroll in the Plan within 30 days of experiencing a qualified change in status as defined by the Plan and the relevant Department of Treasury regulations D. I may be entitled to a Medical Waiver Payment ( Waiver Payment ) if I am participating in another medical insurance plan during the entire period when this waiver is in effect. I am currently participating in the following medical insurance plan: OTHER COVERAGE INFORMATION Coverage: Individual Group Plan Name: Plan Number: E. Waiver Payments are subject to the terms and conditions set forth in the collective bargaining agreement, personnel policy manual or individual contract covering my position, as that agreement, manual or contract may be revised from time-to-time. Signature
Flexible Spending Account Oakland University #140235 EMPLOYEE INFORMATION Name: SSN#: Address: G-ID#: City: State: Zip: Birth : E-mail: Phone: Gender: Female Male SECTION I: BENEFIT ELECTION **I understand that the cost of over-the-counter medicines and drugs will only be reimbursed if they are purchased with a physician s prescription.** I elect to allocate the following amounts for the purchase of the benefits chosen below: Oakland University and I hereby agree that my cash compensation will be reduced as outlined below and will be taken from my pay in equal installments during the plan year. My pay schedule is: ( ) Monthly ( ) Bi-weekly (please check one) Dependent Daycare Reimbursement Enrollment: Total Amount Desired to Fund Dependent Daycare Flexible $ PER PAY ($ Annually) Spending Account ($5,000.00 maximum, $64.00 minimum) Health Care Reimbursement Enrollment: Per Pay Period Election (Note: Do not include employer contributions in this amount) Total Amount Desired to Fund Health Care Flexible Spending Account ($2,500.00 maximum, $64.00 minimum) $ PER PAY ( $ Annually)
Flexible Spending Account Oakland University Plan #140235 SECTION II: COMPENSATION REDUCTION REIMBURSEMENT METHOD (Select Only One) Reimbursement Check Mailed to Home * Reimbursement Direct Deposit** For Direct Deposit: Checking Savings IF YOU ARE SIGNING UP FOR DIRECT DEPOSIT FOR THE FIRST TIME OR YOUR BANKING INFORMATION HAS CHANGED YOU MUST ATTACH A VOIDED CHECK OR DEPOSIT SLIP. * By electing to have a check mailed to my home address, I acknowledge that if the check is not cashed 90 days from the date of the check, the amount will revert to the plan, not to my reimbursement account. **By electing direct deposit to my bank account, I acknowledge that I will be responsible for notifying Meritain Health in writing of any changes in my bank information and be responsible for any bank return fees associated with this service. SECTION III: ENROLLMENT AGREEMENT I have received and read my enrollment package. I hereby understand that by signing and submitting this form I am making a binding election concerning my benefits and pay for this Plan Year. I authorize OAKLAND UNIVERSITY to reduce my BI-WEEKLY OR MONTHLY compensation by the amount specified above in order to purchase benefits under the Plan. I understand that this election is irrevocable during the Plan Year unless the revocation is on account of and consistent with a change in family status and falls within Plan guidelines. If for any reason I cease to be employed by OAKLAND UNIVERSITY, my right to receive Health Care Reimbursement Account reimbursements will cease. However, if I continue to make the contributions on a timely basis which I previously made through salary reduction, then the plan shall remain in effect only until the end of the current Plan Year. This Agreement will automatically terminate if the Plan is terminated or discontinued. This Agreement is subject to the terms of the OAKLAND UNIVERSITY Cafeteria Plan; it shall be governed by and construed in accordance with the laws of the State of Michigan; and it revokes any prior compensation reduction agreement and election of additional benefits forms. Employee Signature Employer Signature