Flexible Benefits Program Enrollment And Change Form Page 2

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6. Member/Dependent Information

(If enrolling in an HMO medical plan, please be sure to designate a primary care physician for

yourself and your dependents. You may add additional dependents on a separate sheet of paper. Also, you must attach documentation that

supports the relationship for each dependent; required documentation is listed on the following page.)

RELATION-

DATE OF

SOCIAL SECURITY

PHYSICAN NAME

NAME

GENDER

SHIP

BIRTH

(M/F)

NUMBER

(HMO only)

(LAST, FIRST, M.I.)

7. Other Coverage

Do you or your dependent(s) have additional health plan coverage?

Medicare:

Yes – Entitlement Date:

Medical:

Yes

Dental:

Yes

If yes, provide name of carrier(s), phone number(s), policy number(s), and sponsoring employer.

8. Signature

I certify the information on this form is complete and correct, and that all dependents listed meet the eligibility rules of the plan(s) in which I have enrolled

them. I authorize County of Ventura HR/Benefits to perform any investigation necessary to verify eligibility for myself and/or my dependent(s). I understand

that misstatements, material misrepresentations, or omissions may result in my coverage being void as of its effective date with no benefits payable. I also

understand and agree that:

• I received a copy of the Flexible Benefits Program Benefit Plans Handbook, and I have read descriptions of benefits plans in which I am enrolling.

• My coverage elections on this form cannot be revoked or modified until the next open enrollment period, unless I have a qualifying change in status as

defined by the IRS (see Benefit Plans Handbook, Chapter 1).

• I will verify that the enrollments and deductions I have authorized on this form have been implemented by reviewing my paystub for accuracy during the

first pay period my selections are effective. I agree that failure to report an error within 30 days of the error’s first appearance on my biweekly paystub is an

affirmative election of the benefits listed on the paystub.

• I will notify the County immediately if I and/or my dependents become ineligible. In the event ineligibility is determined, I understand and agree that

coverage will be terminated retroactive to the date I/we became ineligible. I authorize the Auditor-Controller to adjust the amount of payroll

deductions/reductions/credits (including retroactive adjustments) necessary to correct any premium over-payments or under-payments.

• My pre-tax pay will be reduced by the amount of any required contributions noted for the coverage(s) elected after my flexible credits have been applied

(flexible credit amounts are listed on page 3 of this form). My unspent flexible credits will be taxed and added to my paycheck as “Cash Back."

• My enrolled dependents and I are bound by all the terms and conditions of the plans in which I am enrolling.

• The plan administrator and health care professionals/facilities/representatives are authorized to obtain and/or release medical information from/to

appropriate providers/agencies if needed to provide necessary health care services and/or administrative services and/or claim adjudication for myself and

my enrolled dependent(s).

• A photocopy of this form is as valid as the original.

•

If a disagreement arises regarding coverage under a plan, the dispute or claim shall be submitted to the grievance and/or binding arbitration process as

specified by the plan, and not by lawsuit or resort to court process, except as provided by California law.

Signature

Date

If you are eligible to participate in the Flexible Benefits Program but DO NOT WANT TO ENROLL, read this WAIVER OF BENEFITS and sign and date where indicated:

WAIVER OF BENEFITS: I have been informed about the County’s Flexible Benefits Program. I understand that, if eligible, I am entitled to a Flexible Credit Allowance

each pay period if I am enrolled in the Ventura County Flexible Benefits Program. I choose not to enroll and thereby waive and forfeit the County Flexible Credit

Allowance. I understand that this decision is binding and that I will not have another opportunity to enroll until the next annual Flexible Benefits Program open

enrollment period.

Signature (ONLY SIGN IF YOU DO NOT WANT TO PARTICIPATE IN THE FLEXIBLE BENEFITS PROGRAM)

Date

FOR OFFICE USE ONLY

Department Authorization (Sign & Date)

HR/Benefits Authorization (Sign & Date)

Effective Date

Medical Plan Group ID #

LTD Cert. Sent

Life Ins. Cert. Sent

COBRA Rights Sent (new spouse)

PY 2016 – revised 10/16/15