Form Ers Gi-1.180 - Benefits Election Form - Employees Retirement System Of Texas
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3BENEFITS ELECTION FORM
You may complete your benefits election either by:
Information provided to ERS is maintained for managing your benefits.
• Using your online account at , or
If you have questions about your information, or believe that information
• Send this completed form to your benefits coordinator
provided to ERS may be incorrect, please notify your Benefits Coordinator
or HHS Employee Service Center for employees at HHS
or HHS Employee Service Center.
enterprise agencies
SECTION A: EMPLOYEE DATA (To be completed by employee.)
Social Security Number/National ID (SSN)
Employee ID
First Active Duty Date
Employee Name: First, MI, Last
Eligibility County
Mailing Address
o Check if new
City
State
ZIP Code
Phone Number
o Home o Cell (
)
Email Address
Gender
Date of Birth
o M
o F
Agency Name
Dept ID/Agency Number
Employee Class
Insurance Pay Rate
Employee SSN/National ID Correction
Employee Name Change or Correction
Date of Birth Correction
Please provide this information, as it could affect the waiting period for your medical insurance.
• Were you covered as a dependent under the Texas Employees Group Benefits Program (GBP) at the time of your hire? o Yes o No
If yes, please provide the Social Security number of the person covering you: _________________________________________________
• Are you a University of Texas (UT) or Texas A&M University (TAMU) employee or dependent transferring to this GBP-participating agency or institution without a break in
health coverage? o Yes o No Date coverage ends ____________
If yes, please provide proof of no break in coverage to your benefits coordinator. If you are a Health and Human Services (HHS) Enterprise employee, provide the proof to
HHS Employee Service Center.
• Are you recently rehired with the same state agency within 90 days of leaving active military duty? o Yes o No
If yes, please provide your military release date: _______________.
SECTION B: ACTION (Mark appropriate choice.)
DTA o FTE to PTE/PTE to FTE OR Retiree RTW/Retiree LTW
FSC o Family Status Change
HIR o New Hire
LOA o Leave of Absence
PHC o Post Hire Change
REH o Rehire
RFL o Return from Leave
SECTION C: REASON CODE (See Family Status Change reference table on page 3 before completing.)
Complete for changes during the plan year.
Reason Code: _________
Event Date: ________________ (mm-dd-yyyy)
SECTION D: BENEFITS OPTIONS (Mark appropriate choices.)
Optional Benefits
Health Options
(Newly hired employees may elect benefits on first active duty date or within 31 days of hire/rehire without enrolling
in health coverage.) Effective date, if different from hire/rehire date ______________________ (mm-dd-yyyy)
Optional Term
Voluntary
Dependent Term
Short-term
Long-term
Health
Dental
Vision
Life Insurance**
AD&D
Life Insurance**
Disability**
Disability **
o Waive
o Waive
o Waive
o Waive
o Waive
o Waive
o Waive
o Waive
o HealthSelect
of Texas
o State of Texas Dental
o State of
o Election I
o You Only
o Elect
o Elect
o Elect
SM
Choice Plan
Texas Vision
o Election 2
SM
o Consumer Directed
o You + Family
o Add/Drop
o Election 3
HealthSelect
o HumanaDental DHMO
o Add/Drop
Dependent
SM
$___________
o Election 4
Dependent
(See Section E)
o HMO Name/City
o State of Texas Dental
Amount
(See Section E)
Discount Plan
SM
_______________________
o Add/Drop Dependent
o Add/Drop Dependent
(See Section E)
(See Section E)
o Opt-Out*
If you want to elect a TexFlex health, dependent care, or limited account as a new enrollee or due to a qualifying life event,
(By checking Opt-Out, you also
you must complete the TexFlex Enrollment Change Form. If you want to enroll in the Commuter Spending Account for parking
certify that you have comparable
or transit as a new enrollee or make changes, you must complete the Commuter Spending Account Form.
coverage. Excludes Medicare.)
* A monthly credit of up to $60 (or $30 for part-time participants) can be applied to optional coverage (dental and AD&D, excludes State of Texas Dental Discount Plan).
** To add this coverage will require evidence of insurability (EOI). Request the EOI application online by signing into your online account at , or contact
your benefits coordinator/HHS Employee Service Center.
Employee Tobacco-User Certification: If you are enrolling in the GBP health plan, have you used any type of tobacco product five or more times in the last three months?
This includes but is not limited to cigarettes, pipes, cigars, cigarillos, snuff or chewing tobacco products. o Yes o No
Continue to next page to complete form.
ERS GI-1.180 (R 6/2016) (Page 1 of 3)
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