08-26-2013 Council Work Session Packet

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CITY OF ORONO FLEXIBLE BENEFITS ENROLLMENT FORM After-Tax Premiums Per Month ASSURANT LONG TERM D1SA81LITY COVERAGE: Enter the monthly costs in Box 9. Ltd Policy Number��'�� L��S Indicate if this is a change from present coverage: ❑ change �]/f-io change PRESENT INCREASE/ GRAND EFF.DATE ANNUAL SALARY AMOUNT DECREASE TO2TAL (OFFICE USE ONLY) Employee Long-Term Disability $ $ $ -J, �� 9 �� COLONIAL SHORT TERM DISABItITY COVERAGE: Enter the monthly costs in Box 9A. Employee Short-Term Disability $ $ $ `�`� 9A� y� . Z Z LONG TERM CARE $ Box 90A. 10A. SUPPLEMENTAL LIFE COVERAGE OPTIONS:Enterthe month/y costs in Boxes!1, 12,8 13 Indicate if this is a change from present coverage: ❑ change Bl no change PRESENT INCREASE/ GR,4ND EFF.DATE AMOUNT DECREASE TOTAL (OFFICE USE ONLY) Employee Additional Life $ $ $��i�_ ��. 3`� Spouse Life $ $ $ Dependent Life Insurance ❑ Yes ❑ No 12 Dependent Life $5000 $10,000 �.7V • Complete evidence of insurability on separate form(forms available from Human Resources) 13. •�� MN NCERS Plan Life trtsurance $16.00. Enter tota/in Box 14. �4� �(,,� MONTHLY COST OF AFTER-TAX BENEFITS Add Boxes 9 through 14 and enter tota!in Box 15. c� 15. �/�� 4Z TOTAL MONTHLY COST OF ELECTED BENEFITS Total Cost of Monthly Premiums Add Pre-tax Premiums (Box 8)+After-tax Premiums(Box 15)=Total Monthly Cost of All Benefits. Enter total in Box 16. 16' 7�-'-C'L� EMPLOYER CONTR/BUTION Electing Medical$ �u' Waiving Medical� 1�. ��S, �' EMPLOYEE CONTR1BUTlONS (This is your cost of Bene�ts) ,$ ls-� 4� If the total cost of your Benefits entered in Box 16 exceeds the Employer Contribution in Box 17.the difference will be deducted from your paychecks in either pre-tax or after-tax dollars,depending on your election. The actual dollar amount deducted per paycheck may vary depending upon the number of paychecks you receive during the month and when deductions are made. Enter the difference in Box 18. CASH BENEFlT �s� 19. ��', �/ ❑ If Box 16 is less than Box 17,enter the difference in Box 19. This amount will be added to your paycheck as taxable income.................................................................................................. � OR �LI I elect to take any taxable income listed in Box 19 and make an employee contribution to my 457 Plan. 1 understand that this Plan is not and cannot be a formal part of the Cafeteria Plan. I understand that in order to enroll in the 457 Plan I must complete the appropriate forms. I hereby authorize my employer to make the employer conMbution plus my employee payroll deduclions,if any,indicated above for the Plan Year. I understand that the payroll deduction amounts above will be available for the reimbursement of my qualifying expenses incuned during the Plan Year and/or for the payment of my premiums in accordance with the terms of the formal Plan Documents. On behalf of myself and anyone enrolled on or added to this application("Us"), I authorize any health care professional or entity to give BCBS Minnesota or any of its designees any and all records or information pertaining to medical history or services rendered to Us.I further consent,on behalf of Us,to BCBS Minnesota's use and disclosure of protected health information tor routine purposes,including payment,treatment and health care operations,described in the Privacy Notice on the back of this form.BCBS Minnesota may use and disclose our protected health information for routine purposes for as long as necessary in Ihe connection with the coverage provided to Us.For purposes of facilitating enrollment this consent also authorizes BCBS Minnesota to obtain information about Us for 26 months from the date of signature.I understand that I have the nght to request restndions on the use or disclosure of protected health information.BCBS Minnesota is not required to agree to any such restrictions,but if it does agree,BCBS Minnesota will abide by the terms of the restrictions.I understand that I have the nght to review the Privacy Nolice before signing this form.I also understand that BCBS Minnesota reserves the right to change its Privacy Notice,in which case I will be provided with a revised Privacy Notice.This authorization does not extend to a release conceming Ihe performance of,or results of,a test to determine the presence of the HIV antibody or other bloodbome pathogen for persons as described on the front cover of this enrollment form.I also authorize on behalf of Us the use of a Social Security Number for the purpose of identificatpn.The information provided on this application is accurate and complete.I understand and agree that any omissions or incorrect statements knowingly made by Us on this