Form HR102 "Annual Enrollment Form - the Texas a&m University System" - Texas

ADVERTISEMENT
ADVERTISEMENT

Download Form HR102 "Annual Enrollment Form - the Texas a&m University System" - Texas

387 times
Rate (4.4 / 5) 19 votes
Print Form
Clear Fields
The Texas A&M University System
HR 102 (7/16)
System Member:
Annual Enrollment Form
With few exceptions, you have the right to request, receive, review and correct
information about yourself collected using this form.
1. Name
2.
Last (please print)
First
MI
UIN or Social Security number
3. Home address
Street Address
City
State
ZIP code
4. If you have a spouse/parent/child who currently works for The Texas A&M University System, please provide his/her
name
and UIN/Social Security number
Office use only: ED
TOBACCO USE
5. I
have
___ have not ___ used tobacco products within the last 3 months.
HEALTH
Office use only: ED
To add or drop dependents, you must complete a Dependent Enrollment/Change Form (HR 101).
6.
I want to enroll in the following health plan: __________________________________________
(Complete a Beneficiary Designation Form for Basic Life, if applicable)
7.
I want to cancel my System health coverage ______
8.
If cancelling, I have other health coverage. Yes ____ No ____ (If no, go to question 10).
9.
If yes, I have other health insurance through (pick one of the following, then skip question #10):
An A&M System-offered plan as a dependent
O
A state-provided plan such as the Employees Retirement System or University of Texas System as a former employee
O
(if yes, skip to #13.)
A state-provided plan such as the Employees Retirement System or University of Texas System as a dependent
O
Another company, affiliation plan or Medicare, Medicaid or other government-offered plan
O
10. I want to keep Basic Life coverage, but I understand that I must pay for this coverage myself. Yes ____ No ____ (Proceed to the next section in
which you wish to make changes on this form.)
11. I want to enroll in Alternate Basic Life. Yes ____ No ____ (If you answer yes, complete #12) You must also complete a Beneficiary Designation
Form. If you currently have no life insurance or only $7,500 in coverage, you will need to provide evidence of good health to
increase coverage to $50,000.
12. I want half of the employee-only employer contribution applied to the premiums for Alternate Basic Life, dental, vision, Accidental Death and
Dismemberment and Long-Term Disability, if I am enrolled in these coverages. Yes __ No __
If you do not have A&M System health coverage but certify that you have other health coverage, you may enroll in Alternate Basic Life
or Optional Life, but not both.
Office use only: ED
DENTAL
To add or drop dependents (unless cancelling all coverage), you must complete a Dependent Enrollment /Change Form (HR 101).
13. I want to enroll in/change to A&M Dental ____ Dental HMO ____
14. I want to cancel coverage for myself and all covered dependents ____
VISION
Office use only: ED
To add or drop dependents (unless cancelling all coverage), you must complete a Dependent Enrollment /Change Form (HR 101).
15. I want to enroll ____
16. I want to cancel coverage for myself and all covered dependents ____
OPTIONAL LIFE
Office use only: ED
You may not enroll in Optional Life if you are covered under Dependent Life by a spouse who works for The Texas A&M University
System or if you are enrolled in Alternate Basic Life. Retirees must provide evidence of good health to enroll in or increase their
Optional Life coverage. Employees must provide evidence of good health if enrolling, increasing coverage or choosing a
coverage amount of four, five or six times salary.
18. Employee: I want to decrease coverage to (check one):
Date Stamp
½
1
2
3
4
5
times my annual salary.
19. Retiree: I want to decrease coverage to $___________
(amount must be more than $5000, and it must be a multiple of $1,000)
20. I want to cancel my coverage ______
Print Form
Clear Fields
The Texas A&M University System
HR 102 (7/16)
System Member:
Annual Enrollment Form
With few exceptions, you have the right to request, receive, review and correct
information about yourself collected using this form.
1. Name
2.
Last (please print)
First
MI
UIN or Social Security number
3. Home address
Street Address
City
State
ZIP code
4. If you have a spouse/parent/child who currently works for The Texas A&M University System, please provide his/her
name
and UIN/Social Security number
Office use only: ED
TOBACCO USE
5. I
have
___ have not ___ used tobacco products within the last 3 months.
HEALTH
Office use only: ED
To add or drop dependents, you must complete a Dependent Enrollment/Change Form (HR 101).
6.
I want to enroll in the following health plan: __________________________________________
(Complete a Beneficiary Designation Form for Basic Life, if applicable)
7.
I want to cancel my System health coverage ______
8.
If cancelling, I have other health coverage. Yes ____ No ____ (If no, go to question 10).
9.
If yes, I have other health insurance through (pick one of the following, then skip question #10):
An A&M System-offered plan as a dependent
O
A state-provided plan such as the Employees Retirement System or University of Texas System as a former employee
O
(if yes, skip to #13.)
A state-provided plan such as the Employees Retirement System or University of Texas System as a dependent
O
Another company, affiliation plan or Medicare, Medicaid or other government-offered plan
O
10. I want to keep Basic Life coverage, but I understand that I must pay for this coverage myself. Yes ____ No ____ (Proceed to the next section in
which you wish to make changes on this form.)
11. I want to enroll in Alternate Basic Life. Yes ____ No ____ (If you answer yes, complete #12) You must also complete a Beneficiary Designation
Form. If you currently have no life insurance or only $7,500 in coverage, you will need to provide evidence of good health to
increase coverage to $50,000.
12. I want half of the employee-only employer contribution applied to the premiums for Alternate Basic Life, dental, vision, Accidental Death and
Dismemberment and Long-Term Disability, if I am enrolled in these coverages. Yes __ No __
If you do not have A&M System health coverage but certify that you have other health coverage, you may enroll in Alternate Basic Life
or Optional Life, but not both.
Office use only: ED
DENTAL
To add or drop dependents (unless cancelling all coverage), you must complete a Dependent Enrollment /Change Form (HR 101).
13. I want to enroll in/change to A&M Dental ____ Dental HMO ____
14. I want to cancel coverage for myself and all covered dependents ____
VISION
Office use only: ED
To add or drop dependents (unless cancelling all coverage), you must complete a Dependent Enrollment /Change Form (HR 101).
15. I want to enroll ____
16. I want to cancel coverage for myself and all covered dependents ____
OPTIONAL LIFE
Office use only: ED
You may not enroll in Optional Life if you are covered under Dependent Life by a spouse who works for The Texas A&M University
System or if you are enrolled in Alternate Basic Life. Retirees must provide evidence of good health to enroll in or increase their
Optional Life coverage. Employees must provide evidence of good health if enrolling, increasing coverage or choosing a
coverage amount of four, five or six times salary.
18. Employee: I want to decrease coverage to (check one):
Date Stamp
½
1
2
3
4
5
times my annual salary.
19. Retiree: I want to decrease coverage to $___________
(amount must be more than $5000, and it must be a multiple of $1,000)
20. I want to cancel my coverage ______
HR 102 (Annual Enrollment Form) pg. 2
DEPENDENT LIFE
Office use only: ED
You may not enroll your spouse if your spouse has Optional Life or Alternate Basic Life coverage as an employee of The Texas A&M University
System. To drop dependents (unless you’re cancelling all coverage), you must complete a Dependent Enrollment/Change Form. To enroll dependents or
switch from Dependent Life Plan B to Plans A or C, you must provide evidence of good health.
20. I want to change to the flat rate Plan B _____
21. I want to cancel all Dependent Life Coverage ______
ACCIDENTAL DEATH AND DISMEMBERMENT
Office use only: ED
22. Plan option: Employee coverage
Family coverage
23. Coverage amount of: $
. (Limited to the greater of $250,000 or 10 times your Sept. 1, 2017 salary, not to exceed $800,000.)
24. I want to cancel my coverage.
25. I am enrolling in AD&D coverage for the first time, and I have designated the following beneficiaries (attach an additional sheet if necessary):
Primary Beneficiary(ies)
Name
Relationship
Distribution by %
Address (Street/P.O. Box, City, State, ZIP)
Secondary Beneficiary(ies)
Name
Relationship
Distribution by %
Address (Street/P.O. Box, City, State, ZIP)
LONG-TERM DISABILITY*
Office use only: ED
26. I want to enroll in coverage. _____
27. I want to cancel my coverage. _____
*Pre-Existing Condition Limitation: A pre-existing condition is any injury or illness for which you have consulted a physician, received medical treatment, care
or services (including diagnostic measures), taken prescribed drugs or medicines, or incurred expenses during the 3 months prior to the effective date of your insurance.
If you become disabled due to a pre-existing condition, you will not receive benefits unless your disability begins more than 12 months after the effective date of your
coverage.
FLEXIBLE SPENDING ACCOUNTS
Office use only: ED
If you work for less than 12 months a year, you can enroll only in the nine-month option.
(Sept.-May)
(Sept.-Aug.)
Monthly Amount
Annual Total
28. Health Care Account
9 months
12 months
29. Dependent Day Care Account:
9 months
12 months
Health Care: Monthly minimum $20, annual maximum $2,550. Dependent Day Care: Monthly minimum $40, annual maximum $2,000
30. I want my Spending Account reimbursements to be deposited into the same account as my paycheck.
I want to cancel my: Health Care Account
Dependent Day Care Account
31.
Beginning in FY17, anyone who enrolls in the Health Care Flexible Spending Account will automatically receive a debit card with no annual fee charged to the participant.
Read the following agreements and sign below.
Payroll Deduction/Billing Agreement: I authorize The Texas A&M University System to deduct from my earnings the amount required to cover
my share of the premiums for these coverages. If I am being billed, I understand that failure to pay my premium(s) will result in cancellation of coverage.
Insurance Cancellation Agreement: If cancelling any insurance coverage, I understand that in order to participate in the future I may be required to furnish
evidence of good health at my own expense. Coverage is subject to the carrier’s approval and is not guaranteed. In addition, for certain plans I may enroll only during
certain enrollment periods and/or be subject to pre-existing condition limitations.
Release of Information: I understand that certain information collected using this form will be sent to the insurance carriers of the plans in
which I enroll. The A&M System and the insurance carriers will treat this information as confidential. .
Tobacco User Agreement: I understand that if I have indicated on this form that I am not a tobacco user and this proves to have been a false statement, my coverage
and any associated dependent benefit coverage may be cancelled.
If you are designating beneficiaries, this form must be witnessed. The date of the witness’ signature must be the same as yours.
The witness cannot be a beneficiary or your relative.
Original Signature Required
Date (MM/DD/YYYY)
Witness’s name (printed)
Signature of witness in ink (blue preferred)
Original Signature Required
Signature of employee/retiree in ink (blue preferred)
Daytime phone number
Signature Date (MM/DD/YYYY)
Page of 2