08-26-2013 Council Work Session Packet

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CITY OF ORONO FLEX/BLE BENEFITS ENROLLMENT FORM After-Tax Premiums Per Month ASSURANT LONG TERM D/SAB/LITY COVERAGE: Enter the monthly costs in eox 9. Ltd Policy Number Indicate if this is a change from present coverage: ❑ change � no change 7��-�0 PRESENT INCREASE! GRAND EFF DATE ANNUAL SALARY AMO/U�NT\ DECREASE T (OFFICE USE ONLY) Employee Long-Term Disability $ v $�$�� 9' ��f. �� r+v COLONIAL SHORT TERM DISABILITY COVERAGE: Enter the monthly costs in Box 9A. Employee Short-Term Disability $� $�P�� 9A. �f�p ;;{� ,�� � LONG TERM CARE $ � Box 10A. 10A. SUPPLEMENTAL LIFE COVERAGE OPTIONS:Enter the monthly costs in eoxes 11, 12,8 13 Indicate if this is a change from present coverage: ❑ change ❑ no change PRESENT INCREASE/ GRAND EFF.DATE AMOUNT DECREASE TOTAL (OFFICE USE ONLY) Employee Additional Life $ $ $ �� Spouse�ife $ $ $ Dependent Life Insurance ❑ Yes ❑ No 12_ Dependent Life $5000 $10,000 • Complete evidence of insurability on separate form(forms available from Human Resources) 13. MN NCERS Pian ❑ Life Insurance $16.00. Enfer tota/in Box 14. 14. MONTNLY COST OF AFTER-TAX BENEFITS Add eoxes 9 through 14 and enter tota/in 8ox 15. �� r,�C�l 15. v i , TOTAL MONTHLY COST OF ELECTED BENEFITS Total Cost of Monthly Premiums Add Pre-taz Premiums(Box 8)+After-tax Premiums(Box 15)=Total Monthly Cost of 16. ' (��, � All Benefits. Enter total in Box 16. EMPLOYER CONTR/BUTION Electing Medical$ Waiving Medical�_ ��. � � � — EMPLOYEE CONTRIBUTIONS (This is your cost of Benefits) J�� 18. 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 BENEFIT �s. ❑ If Box 16 is less than Box 17,enter the difference in Box 19. This amount will be added to your paycheckas 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. � I hereby authonze my employer to make the employer contribution plus my employee payroll deductions,if any,indicated above for the Plan Year. I understand that the payroll detluction amounts above will be available for the reimbursement of my qualifying expenses incurretl tluring the Plan Year andior for the payment of my premiums in accordance with the terms of the formal Plan Documents. On behalf of myself and anyone enrolletl on or added to this application('Us"),I authonze any health care professional or entity to give BCBS Minnesota or any of iLs designees any antl all rec�s or infortnation pertaining to medical history or services rentlered to Us.I further consent,on behalf of Us,to BCBS Minnesota's use and disclosure of protected health mformation for routine purposes,inGuding payment,treacment 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 the connedion with the coverage provided to Us.For purposes of facilitating enrollment Nis consent also authorizes BCBS Minnesota to obtain information about Us for 26 months from the date of signature.I untlerst2nd that I have the right to request restrictions on the use or disclosure of protected health informatlon.BCBS Minnesota is not required to agree to any such restrictions.but if it tloes agree,BCBS Minnesota will abitle by the terms of the restridions.I understand that I have the nght to review the Privacy Notice before signing this form.I also understand that BCBS Minnesota reserves the right to change its Privacy Notice,in which case I vrill be provided with a revised Privacy Notice.This authorization dces not eMentl to a release concerning the performance of,or results of,a test to deterrtdne the presence of the HIV an6body 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 Secunty Numoer for the purpose of i�lificationi he i�formation provided on this application is accurate and complete.I understand and agree that any omissions or incorrect statemenLs knowingly made by Us on this