Form Cef15 - Contractual / Variable Hour Employees Health Benefits Enrollment And Change Form For January - December 2016 Page 4

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ENROLLMENT FOR JANUARY 2016-DECEMBER 2016

Life Insurance Plan (continued)

SPOUSE

SECTION 2: SPOUSE INSURANCE

NOTE: You cannot enroll your family members unless you, the employee, are enrolled. You cannot select an amount for your dependents greater than

50% of the amount selected for yourself.

OPTIONS-Choose only one

Choose a Coverage Amount in increments of $5,000 up to 1/2 of the amount

chosen for yourself, up to $150,000:

Having selected Life Insurance for myself, I

wish to have Life Insurance on my spouse.

STOP-If you choose an amount greater than $25,000, you must fill out a Life Insurance

Evidence of Insurability for your spouse. The life insurance vendor will contact you about

I currently have Life Insurance for my spouse

completing this form. Amount over $25,000 will not be effective

and am making a change.

until we receive approval from our life insurance carrier.

No, I do not want Life Insurance on my spouse.

Fill in the amount of Benefit

0 0 0

Cancel Life Insurance on my spouse.

CHILDREN

SECTION 3: CHILD(REN) INSURANCE

NOTE: You cannot enroll your family members unless you, the employee, are enrolled. You cannot select an amount for your dependents greater than

50% of the amount selected for yourself.

OPTIONS-Choose only one

Choose a Coverage Amount in increments of $5,000 up to 1/2 of the amount

Having selected Life Insurance for myself, I

chosen for yourself, up to $150,000:

wish to have Life Insurance for my child(ren).

STOP-If you choose an amount greater than $25,000, you must fill out a Life Insurance

I currently have Life Insurance for my child(ren)

Evidence of Insurability for each covered child. The life insurance vendor will contact you about

and am making a change.

completing this form. Amount over $25,000 will not be effective until we receive approval from

No, I do not want Life Insurance on my

our life insurance carrier.

child(ren).

Fill in the amount of Benefit

Cancel Life Insurance on my child(ren).

0 0 0

Employee Signature

Please enroll me for the benefits indicated on this form. I understand the benefits and limitations provided by the various plans. To the extent deemed necessary

by the Plan Administrator for the proper administration of my coverages, I authorize the release of all medical records and related information pertaining to me or

my dependents. The personal information provided on this enrollment form is warranted to be complete, accurate, and in accordance with Department of Budget and

Management (DBM) regulations. The Mandatory Insurer Reporting Law 42 U.S.C. 1395y(b)(7) requires group health plans to report SSNs in order for Medicare

to coordinate payments with other insurance benefits. Please refer to our Notice of Privacy Practices in the Benefit Guide and on our website for more detailed

information. I understand that I cannot cancel or change my enrollment except during an Open Enrollment period or as a result of a change in status

permitted by COMAR 17.04.13.04 and IRS Section 125.

I understand that the benefits program offered by the State is subject to modifications and changes and that the benefits I have chosen on this enrollment form are only

in effect for the current plan year. The State of Maryland reserves the right to modify any of the benefits provided and gives no assurances, expressed or implied, that any

coverage obtained hereunder will continue beyond the end of the current plan year. I certify that neither I nor my covered dependents are covered under another

State of Maryland employee’s or retiree’s membership for which I or they are enrolled on this form.

I certify that I and any dependents listed for coverage are eligible for coverage. I understand that enrollment in benefits to which I or my dependents are not entitled

is considered fraud. In all cases I am responsible for the accuracy of my benefits, coverage levels and premiums. I further understand that if I willfully misrepresent

the eligibility of myself or my dependents on my benefits application, or fail to take the necessary action to remove ineligible dependents, or in any way obtain benefits to

which I am not entitled, my benefits will be cancelled. I may be required to repay any claims and insurance premiums which have been paid inappropriately, and I may face

criminal investigation and prosecution.

I further solemnly affirm under the penalties of perjury under applicable state laws that any dependent information I have provided is true and accurate. I understand

that willful falsification of information contained in this attestation can result in referral of the matter for investigation and prosecution, the termination of enrollment

and coverage of the person identified as my dependent, and the termination of coverage for myself (the employee). I understand that a civil action may be brought

against me for any losses, including reasonable attorney fees because of a false statement contained in this attestation, and that other serious consequences may result.

I further attest and agree that if a dependent’s status changes and the dependent is no longer eligible, I will notify my Agency Benefit Coordinator or the Employee

Benefits Division immediately to remove this dependent from my coverage. I also agree to provide the required documentation as outline in the current plan year’s

Benefits Guide to substantiate the information I have provided, and affirm that each enrolled dependent is my true tax dependent.

X __________________________________________________

_____/______/_______

Employee Signature

Date

NOTE: If you have any questions concerning the benefits and services that are provided by or excluded under this agreement, please contact the plan’s member

service department before signing this application. Plan phone numbers are listed on the inside front cover of the Benefits Guide.

Agency Signature -

Agency Must Sign Here FORMS WILL NOT BE PROCESSED WITHOUT AN AGENCY SIGNATURE

FISCAL OFFER – PLEASE PRINT THE FOLLOWING FOR SUBSIDY ELIGIBLE CONTRACTUAL EMPLOYEES:

Appropriation Code:

__ __ __

__ __ __ __ __

__ __ __

__ __ __ __

Agency

PCA

R Stars Sub Object

_________________________________________________________________ ____________________________________________________________________

Fiscal Officer Name & Phone Number

Fiscal Officer Signature

I hereby certify that the person applying for enrollment is employed by the Agency. I certify that the employee works 30 hours a week or 130 hours a month and is

eligible for the State Subsidy for medical and prescription coverage. I have reviewed the form and accompanying documents for accuracy.

X __________________________________________________

_____/______/_______

(_____) _______________

______________________

Agency Benefits Coordinator

Date

Work Phone Number (Ext.)

Department

__________________________________________________

(_____) _______________

Agency Benefits Coordinator Email Address