Form Hr 102 (7/16) - Annual Enrollment Form Page 2

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.

HR 102 (Annual Enrollment Form) pg. 2

DEPENDENT LIFE

Office use only: ED

You may not enroll your spouse if your spouse has Optional Life or Alternate Basic Life coverage as an employee of The Texas A&M University

System. To drop dependents (unless you’re cancelling all coverage), you must complete a Dependent Enrollment/Change Form. To enroll dependents or

switch from Dependent Life Plan B to Plans A or C, you must provide evidence of good health.

20. I want to change to the flat rate Plan B _____

21. I want to cancel all Dependent Life Coverage ______

ACCIDENTAL DEATH AND DISMEMBERMENT

Office use only: ED

22. Plan option: Employee coverage

Family coverage

23. Coverage amount of: $

. (Limited to the greater of $250,000 or 10 times your Sept. 1, 2017 salary, not to exceed $800,000.)

24. I want to cancel my coverage.

25. I am enrolling in AD&D coverage for the first time, and I have designated the following beneficiaries (attach an additional sheet if necessary):

Primary Beneficiary(ies)

Name

Relationship

Distribution by %

Address (Street/P.O. Box, City, State, ZIP)

Secondary Beneficiary(ies)

Name

Relationship

Distribution by %

Address (Street/P.O. Box, City, State, ZIP)

LONG-TERM DISABILITY*

Office use only: ED

26. I want to enroll in coverage. _____

27. I want to cancel my coverage. _____

*Pre-Existing Condition Limitation: A pre-existing condition is any injury or illness for which you have consulted a physician, received medical treatment, care

or services (including diagnostic measures), taken prescribed drugs or medicines, or incurred expenses during the 3 months prior to the effective date of your insurance.

If you become disabled due to a pre-existing condition, you will not receive benefits unless your disability begins more than 12 months after the effective date of your

coverage.

FLEXIBLE SPENDING ACCOUNTS

Office use only: ED

If you work for less than 12 months a year, you can enroll only in the nine-month option.

(Sept.-May)

(Sept.-Aug.)

Monthly Amount

Annual Total

28. Health Care Account

9 months

12 months

29. Dependent Day Care Account:

9 months

12 months

Health Care: Monthly minimum $20, annual maximum $2,550. Dependent Day Care: Monthly minimum $40, annual maximum $2,000

30. I want my Spending Account reimbursements to be deposited into the same account as my paycheck.

I want to cancel my: Health Care Account

Dependent Day Care Account

31.

Beginning in FY17, anyone who enrolls in the Health Care Flexible Spending Account will automatically receive a debit card with no annual fee charged to the participant.

Read the following agreements and sign below.

Payroll Deduction/Billing Agreement: I authorize The Texas A&M University System to deduct from my earnings the amount required to cover

my share of the premiums for these coverages. If I am being billed, I understand that failure to pay my premium(s) will result in cancellation of coverage.

Insurance Cancellation Agreement: If cancelling any insurance coverage, I understand that in order to participate in the future I may be required to furnish

evidence of good health at my own expense. Coverage is subject to the carrier’s approval and is not guaranteed. In addition, for certain plans I may enroll only during

certain enrollment periods and/or be subject to pre-existing condition limitations.

Release of Information: I understand that certain information collected using this form will be sent to the insurance carriers of the plans in

which I enroll. The A&M System and the insurance carriers will treat this information as confidential. .

Tobacco User Agreement: I understand that if I have indicated on this form that I am not a tobacco user and this proves to have been a false statement, my coverage

and any associated dependent benefit coverage may be cancelled.

If you are designating beneficiaries, this form must be witnessed. The date of the witness’ signature must be the same as yours.

The witness cannot be a beneficiary or your relative.

Original Signature Required

Date (MM/DD/YYYY)

Witness’s name (printed)

Signature of witness in ink (blue preferred)

Original Signature Required

Signature of employee/retiree in ink (blue preferred)

Daytime phone number

Signature Date (MM/DD/YYYY)