Benefits Change Form - University Of Nebraska

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BENEFITS CHANGE FORM
Name ___________________________________________
Last
First
M.I.
University ID Number _____________________
Campus Address ___________________ Zip Code __________
Email Address
Campus Phone ______________________________________
1. ADMINISTRATIVE UNIT
2. PAY CYCLE
3. CHANGE IN STATUS (check one)
[ ] UNL
[ ] IANR
[ ] UNMC
[ ] BIWEEKLY
EMPLOYEE
DEPENDENT
[ ] UNO
[ ] UNK
[ ] UNCA
[ ] MONTHLY
___ ___ / ___ ___ / ___ ___ ___ ___
month
day
year
Change in Status Event: ___________________________
4.
EFFECTIVE DATE
7.
NUFLEX CHOICES
Option
Coverage
___ ___ / ___ ___ / ___ ___ ___ ___
Number
Category
month
day
year
Medical
________
________
Dental
________
________
5.
SPOUSE IS AN EMPLOYEE OF THE
UNIVERSITY OF NEBRASKA
Vision
________
________
Long Term Disability
________
Spouse’s Name:_______________________________
Life Insurance Employer-Provided (1x Annual Budgeted Salary*)
Spouse’s Social Security Number:
Voluntary Life Insurance
________
___ ___ ___ - ___ ___ -___ ___ ___ ___
Accidental Death
________
________
& Dismemberment
6.
TOBACCO/NICOTINE DESIGNATION CHANGE
Dependent Life Insurance
(for life insurance)
Spouse
________
Have you used any form of tobacco or nicotine,
Child(ren)
________
including nicotine substitutes (e.g. patches or gum)
within the last 12 months?
Flexible Spending Account
Health Care
$__________ Total amount through December 31
___Yes ___No If No, complete the following:
Dependent Day Care
$__________ Total amount through December 31
Date quit using tobacco/nicotine
OR
___ ___ / ___ ___ / ___ ___ ___ ___
[ ] Never Used
*Up to a $120,000 maximum.
month
day
year
8.
EMPLOYEE SIGNATURE
I understand and approve the enrollment as indicated above. In accordance with Nebraska Revised Statute §48-1230 (Reissue 2010), I hereby authorize the
Board of Regents of the University of Nebraska (Employer) to deduct from my earnings the amount of my premiums or other contributions (if any) for the
benefit options noted in Section 7 above.
I understand that I will not pay income tax or FICA tax on my medical, dental, vision, long term disability, and employee only AD&D insurance premiums, or
Flexible Spending Account contributions. These benefits are paid through the Flexible Benefits Plan on a pre-tax basis. Coverage for long term care
insurance, voluntary life insurance, dependent life insurance, and family AD&D insurance is not provided through the Flexible Benefits Plan on a pre-tax basis.
Life insurance that exceeds $50,000 may be subject to imputed income. However, my gross salary before these deductions will be used to figure salary
increases or pay-related fringe benefits. Under the Internal Revenue Code regulations, I may not change my benefit elections (Section 7 above) during the
calendar year unless I experience a qualified change in status. For information on what constitutes a qualified change in status, see the detailed benefits
information at (Health Care Flexible Spending Account elections may not be reduced during the calendar year.)
Each year, during the annual enrollment period, I will have the option to change certain coverages whether or not I have had a qualified change in status event
during the calendar year (some benefits may have certain enrollment restrictions). In the future, any application to add or increase coverage for me or any of
my dependents may require proof of insurability for any person proposed for coverage. Any application must be submitted in accordance with university and/or
insurance company guidelines.
If you are declining medical insurance enrollment for yourself or your dependents, including your spouse, because of other medical insurance coverage, you
may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 31 days after your other coverage ends.
In addition, if you have a new dependent as a result of marriage, birth, or adoption, you may be able to enroll yourself and your dependents, provided that you
request enrollment within 31 days after the marriage, birth or adoption.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing
any materially false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance
act, which is a crime and subjects such person to criminal and civil penalties. Any material misrepresentation made by me in the above “Tobacco/Nicotine
Designation,” including my tobacco/nicotine use history, may void the insurance, pursuant to the Incontestable Clause of the policy.
EMPLOYEE SIGNATURE_____________________________________________________________________ DATE _________________________
January 15, 2014

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