08-26-2013 Council Work Session Packet

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CITY OF ORONO FLEX/BLE BENEFITS ENROLLMENT FORM After-Tax Premiums Per Month �SSURANT LONG TERM DISABILITY COVERAGE: Enter the monthly costs in Box 9. Ltd Policy Number�q�ZS Indicate if this is a change from present coverage: ❑ change �no change /� PRESENT INCREASE/ GRAND EFF.DATE NNUAL SALARY D� � AMOUNT DECREASE TOTAL (OFFICE USE ONLY) mployee Long-Term Disability $ C9d0. $ $ �.Gic�O. 9. g� �� :OLONIAL SHORT TERM DISABILITY COVERAGE: Enter the monthly costs in Box 9A. mployee Short-Term Disability $ $ $ 9A• ONG TERM CARE $ g r'�D Box 10A. 10A. C�S. 74 UPPLEMENTAL LIFE COVERAGE OPTIONS:Pnter the monthly costs in Boxes 11, 12,&13 idicate if this is a change from present coverage: ❑ change ,�no change PRESENT INCREASE/ GRAND EFF.DATE AMOUNT DECREASE TOTAL (OFFICE USE ONLY) mployee Additional Life $�_ ,�`�`S(s�$ "" $� "`r" 11. �✓. � pouse Life $ $ $ �ependent Life Insurance ❑ Yes �' No 12 Dependent Life $5000 $10,000 Complete evidence of insurability on separate form(forms available from Human Resources) �3 iN NCERS P/an ❑ Life Insurance $16,00. Enter tota/in Boz 14. 14. iONTHLY COST OF AFTER-TAX BENEFITS Add Boxes 9 through 14 and enter total in Box �5 �� O 5. OTAL MONTHLY COST OF ELECTED BENEFITS Total Cost of Monthly Premiums dd Pre-tax Premiums (Box 8)+After-tax Premiums (Box 15)=Total Monthly Cost of II Benefits. Enter total in Box 16. 16. � 3 �� 'MPLOYER CONTRIBtlTION Electing Medical$ yl , Waiving Medical�_ ��. �`� � MPLOYEE CONTRI6UTIONS (This is your cost of Bene�ts) 2 2 � �� 18. the total cost of your Benefits entered in Box 16 exceeds the Employer Contribution in Box 17.the fference will be deducted from your paychecks in either pre-tax or after-tax dollars,depending on your ection. The actual dollar amount deducted per paycheck may vary depending upon the number of 3ychecks you receive during the month and when deductions are made. nter the difference in Box 18. ASH BENEFIT �9 ❑ 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 ❑I elect to take any taxable income listed in Box 19 and make an employee contribution to my 457 Plan. I 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. ereby authorize my employer to make the employer contnbution plus my employee payroll deductions,if any,indicated above for the Plan Year. I understand that the payroll deduction amounts above will available for the reimbursement of my qualifying expenses incuned dunng the Plan Year and/or for the payment of my premiums in accordance with the terms of the formal Plan Documents. i behalf of myself and anyone enrolled on or added to this application("Us"), I authonze any health care professional or entity to give BCBS Minnesota or any of its designees any and all records or ortnation pertaining to medical history or services rendered to Us.1 further consent,on behalf of Us,to BCBS Minnesota's use and disclosure of protected health information for routine purposes,including yment,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 infortnation for routine purposes for as long necessary in the connection with the coverage provided to Us.For purposes of facilitating enrollment this consent also authonzes BCBS Minnesota to obtain information about Us for 26 months from the te of signature.I understand that I have the right to request restrictions on the use or disclosure of protected health information.BCBS Minnesota is not required to agree to any such restrictions,but if it es agree,BCBS Minnesota will abide by the terms of the restnctions.I understand that I have the nght to review the Privacy Notice before signing this fortn.I also understand that BCBS Minnesota reserves e nght lo change its Pnvacy Notice,in which case I will be provided wi a revised Privacy Notice.This authonzation does not extend to a release conceming the performance of,or results of,a test to termine the presence of the HIV antibody or other bloodbome patho n for persons as described on the front cover of this enrollment fortn.I also authorize on behalf of Us the use of a Social Security mber for the purpose of identification.The information provided on s application is accurate and complete.I understand and agree that anV omissions or incorrect statements knowinolv made bv Us on this