Form Ers Gi-1.180 - Benefits Election Form - Employees Retirement System Of Texas Page 2

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SSN ____________________________________ Employee Name: First, MI, Last __________________________________________________________________

SECTION E: DEPENDENT PERSONAL DATA (and coverage choices.)

Dependent Tobacco-user Certification: If your dependents are enrolled in a GBP health plan, you must certify below if your dependent 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.

Dependent

Date of Birth

Tobacco

Dependent’s Name

Dependent SSN

Gender

Health

Dental

Vision Dep. Life

Relationship*

(Required for 12 months or older)

User

(First, MI, Last)

(mm-dd-yyyy)

o Sp o D

o M

o Yes

o S o O

o F

o No

o Sp o D

o M

o Yes

o S o O

o F

o No

o Sp o D

o M

o Yes

o S o O

o F

o No

o Sp o D

o M

o Yes

o S o O

o F

o No

o Sp o D

o M

o Yes

o S o O

o F

o No

* Relationship Code: Sp – Spouse D or S - Natural or adopted daughter or son O – Other than natural or adopted child. Includes stepchild, foster child, or ward child.

If you are adding a child, you must complete a Dependent Child Certification form (ERS GI 1.081) available at or by calling ERS. You will also be

required to submit documentation proving your dependents’ eligibility.

Did your dependent have GBP coverage under ERS through another member within the last 31 days? o Yes o No

If yes, please provide the Social Security number under which your dependent was covered: _________________________________

Is this dependent a new addition to your household because of this event? Please check one only:

o Adoption

o Acquisition of other than natural child

o Birth

o Not newly acquired

o Marriage

SECTION F: AUTHORIZATION (Carefully read the statements below before you sign and date.)

I authorize payroll deductions for the elections indicated on this Benefits Election Form. I understand that my insurance coverage may be cancelled if I do not pay the

required amounts due, either by payroll deduction or personal payment. I understand that all insurance premiums are deducted on a pre-tax basis, except Dependent

Life, State of Texas Dental Discount Plan, and Disability. I authorize any provider to release any information on persons covered when needed to verify eligibility or to

process an insurance claim/complaint. I understand that insurance participation rules and enrollment and benefits information are available from my benefits coordinator/

HHS Employee Service Center or ERS. I understand that double coverage for dependents is not allowed for health and dental coverage in the Texas Employees

Group Benefits Program (GBP). I understand that state law does not permit me to receive more than one state insurance contribution as either an employee,

retiree, or dependent. I certify that I am familiar with the requirements for enrolling myself and/or dependent(s) in the GBP based on a new/post hire change or a

qualifying life event (QLE). I further certify that my QLE is valid, correct, and allowable under the GBP. I understand that I may be asked to show documentation to

support my QLE and will be required to submit documentation for any newly enrolled dependents, proving their eligibility. I also understand that if I knowingly provide any

materially incorrect, incomplete, untrue, information, I may be permanently expelled from the GBP and/or subject to criminal prosecution.

Notice about Insurance: Funding for health and other insurance benefits for participants in the GBP is subject to change based on available state funding. The Texas

Legislature determines the level of funding for such benefits and has no continuing obligation to provide funding for those benefits beyond each fiscal year.

Tobacco-Use Certification: I certify my understanding and agreement to the following: “Tobacco Products” are cigarettes, cigars, pipe tobacco, chewing tobacco,

snuff, dip or any other products that contain tobacco, and a “Tobacco User” is a person who has used any Tobacco Products five or more times within the past three

consecutive months. If I (or any of my covered dependents): 1) have used Tobacco Products as a Tobacco User; or 2) start using Tobacco Products without notifying

ERS, I will be subject to monetary penalties and may be terminated from participation in the GBP. Also, failure to notify ERS will constitute fraud. Under the penalties

of perjury, the above information is true and correct. Providing or entering false information may disqualify me from continued coverage in the GBP. If I intentionally

misrepresent material facts or engage in fraud, my coverage may be rescinded retroactively to the date of the misrepresentation or fraudulent act. In that event, I will

receive thirty days notice before my coverage is rescinded. Further, if I or any of my covered dependents start using Tobacco Products without notifying ERS, I will be

subject to monetary penalties and such failure to notify ERS will constitute fraud.

If you certified yourself or any of your dependents as a tobacco user, you may be able to participate in Choose to Quit, an alternative to the tobacco-user premium,

if it is right for your health status and complies with your doctor’s recommendations. For more information about this program, visit,

/Employees/Health/Tobacco_Policy.

If you previously certified yourself or any of your dependents as a tobacco user, and you or they have stopped using tobacco for three consecutive months, you must

complete the Tobacco User Certification Form (ERS 2.933) available at , or

change the certification using your online account at .

Employee’s Signature ________________________________________________ Date Signed (mm-dd-yyyy) _____________________

Keep a copy of this form for your files and return the original to your benefits coordinator.

If you are a Health and Human Services (HHS) Enterprise employee, return this form to HHS Employee Service Center.

ERS GI-1.180 (R 6/2016) (Page 2 of 3)