Form Cef14 - Contractual / Variable Hour Employees Health Benefits Enrollment And Change Form For January-December 2015 Page 4

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ENROLLMENT FOR JANUARY 2015-DECEMBER 2015

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 JANUARY 2015-DECEMBER 2015. 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 December 31, 2015. 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.

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.

Is there any other health insurance coverage in which you, your spouse, or any of your dependents are enrolled?

Yes

Effective Date: _____/______/_______

Specify who is covered, name of Insurance Company and Policy Number:________________________________________________________________________________

X __________________________________________________

_____/______/_______

Employee Signature

Date

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