Form Hr 102 (7/16) - Annual Enrollment Form

Download a blank fillable Form Hr 102 (7/16) - Annual Enrollment Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Hr 102 (7/16) - Annual Enrollment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Print Form
Clear Fields
The Texas A&M University System
HR 102 (7/16)
System Member:
Annual Enrollment Form
With few exceptions, you have the right to request, receive, review and correct
information about yourself collected using this form.
1. Name
2.
Last (please print)
First
MI
UIN or Social Security number
3. Home address
Street Address
City
State
ZIP code
4. If you have a spouse/parent/child who currently works for The Texas A&M University System, please provide his/her
name
and UIN/Social Security number
Office use only: ED
TOBACCO USE
5. I
have
___ have not ___ used tobacco products within the last 3 months.
HEALTH
Office use only: ED
To add or drop dependents, you must complete a Dependent Enrollment/Change Form (HR 101).
6.
I want to enroll in the following health plan: __________________________________________
(Complete a Beneficiary Designation Form for Basic Life, if applicable)
7.
I want to cancel my System health coverage ______
8.
If cancelling, I have other health coverage. Yes ____ No ____ (If no, go to question 10).
9.
If yes, I have other health insurance through (pick one of the following, then skip question #10):
An A&M System-offered plan as a dependent
O
A state-provided plan such as the Employees Retirement System or University of Texas System as a former employee
O
(if yes, skip to #13.)
A state-provided plan such as the Employees Retirement System or University of Texas System as a dependent
O
Another company, affiliation plan or Medicare, Medicaid or other government-offered plan
O
10. I want to keep Basic Life coverage, but I understand that I must pay for this coverage myself. Yes ____ No ____ (Proceed to the next section in
which you wish to make changes on this form.)
11. I want to enroll in Alternate Basic Life. Yes ____ No ____ (If you answer yes, complete #12) You must also complete a Beneficiary Designation
Form. If you currently have no life insurance or only $7,500 in coverage, you will need to provide evidence of good health to
increase coverage to $50,000.
12. I want half of the employee-only employer contribution applied to the premiums for Alternate Basic Life, dental, vision, Accidental Death and
Dismemberment and Long-Term Disability, if I am enrolled in these coverages. Yes __ No __
If you do not have A&M System health coverage but certify that you have other health coverage, you may enroll in Alternate Basic Life
or Optional Life, but not both.
Office use only: ED
DENTAL
To add or drop dependents (unless cancelling all coverage), you must complete a Dependent Enrollment /Change Form (HR 101).
13. I want to enroll in/change to A&M Dental ____ Dental HMO ____
14. I want to cancel coverage for myself and all covered dependents ____
VISION
Office use only: ED
To add or drop dependents (unless cancelling all coverage), you must complete a Dependent Enrollment /Change Form (HR 101).
15. I want to enroll ____
16. I want to cancel coverage for myself and all covered dependents ____
OPTIONAL LIFE
Office use only: ED
You may not enroll in Optional Life if you are covered under Dependent Life by a spouse who works for The Texas A&M University
System or if you are enrolled in Alternate Basic Life. Retirees must provide evidence of good health to enroll in or increase their
Optional Life coverage. Employees must provide evidence of good health if enrolling, increasing coverage or choosing a
coverage amount of four, five or six times salary.
18. Employee: I want to decrease coverage to (check one):
Date Stamp
½
1
2
3
4
5
times my annual salary.
19. Retiree: I want to decrease coverage to $___________
(amount must be more than $5000, and it must be a multiple of $1,000)
20. I want to cancel my coverage ______

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2