Benefits Enrollment Change Form (Page 4 of 4) in pdf

2016 Benefits Enrollment/Change Form

Section H: Life Insurance

Aetna

Supplemental

Coverage Level

Information

 Maximum without evidence of good health

Enroll

(EOI): $500,000

1x Annual Base Salary

 Maximum with evidence of good health (EOI): $1,000,000

Decline/Cancel

2x Annual Base Salary

 Coverage amount is rounded up to the nearest $1,000

Change

 At age 70, coverage is reduced by 60%

3x Annual Base Salary

No Change

 At age 75, coverage is reduced by 75%

Dependent

Coverage Level

Information

Enroll

 Aetna Dependent Life Insurance (spouse coverage amount) cannot

Spouse $5,000 / Child(ren) $2,500

exceed 100% of your combined Aetna Basic Life and Supplemental Life

Decline/Cancel

Spouse $15,000 / Child(ren) $7,500

Insurance coverage.

Change

Spouse $25,000 / Child(ren) $12,500

*Requires evidence of good health (EOI) and underwriting approval.

No Change

*Spouse $50,000 / Child(ren) $25,000

Learn More about Aetna EOI rules:

c fo.asu.edu/hr-life

The Hartford

Supplemental

Coverage Level

Information

Enroll

Indicate your Hartford coverage amount

 Available in $5,000 increments

 Maximum: $500,000 or 3x annual base salary, whichever is less

Decline/Cancel

 Salary is rounded down to the nearest $5,000 increment

Change

No Change

Dependent

Coverage Level

Information

$ 2,000

$12,000

Enroll

 Hartford Dependent Life Insurance cannot exceed 100% of your

combined Hartford Basic Life and Supplemental Life Insurance coverage.

$ 4,000

$15,000

Decline/Cancel

 Married faculty and staff members cannot both elect Hartford Dependent

$ 6,000

$50,000

Change

Life. This restriction does not apply to Aetna Dependent Life.

$10,000

No Change

EOI Required?

Aetna

____________ Annual Salary x _____ Coverage Level = ____________ Subtotal

Yes - Added to SS on: ______________

Supp

Subtotal Rounded up to nearest $1,000 = ____________ Coverage

EOI Required?

HR Use

Yes - Added to SS on: _______________

Aetna

Only

____________ Basic + ____________ Supp = ____________ (Total Employee Covg)

Dep

Is employee coverage greater than dependent coverage?

Yes

Is employee coverage greater than dependent coverage?

Hartford

Yes

Dep

____________ Basic + ____________ Supp = ____________ (Total Employee Covg)

Section I: Life Insurance Beneficiaries

Learn more

cfo.asu.edu/hr-lifebeneficiaries

Section J: Acknowledgement and Authorization

I certify under penalty of perjury that the information provided in this application for employee benefits, including social security numbers, addresses, spouse and/or

dependent child(ren) information, is true and accurate. I further understand that providing false information may subject me to a denial of employee benefits, disciplinary

action and prosecution pursuant to A.R.S. §13-2310, 13-2311, 13-2407, 13-2702 and other applicable provisions of the law. I authorize the release of this information

to my employer, the Arizona Department of Administration, and insurance carriers. Further:



I authorize my employer to reduce my salary by pre-tax or after-tax deductions (in accordance with IRC Section 125), either prospectively or retroactively, for my

elected benefits. Any pre-tax contributions are ineligible as itemized deductions for income tax purposes.



I understand that I can only change my benefits during open enrollment or by written notification to HR Benefits within 30 calendar days of a qualified life event.



I understand that while on any unpaid status, I am responsible for paying my benefits premiums. Upon return to paid status, I will be billed or have pre-tax or

after-tax payroll deductions. If I fail to pay premiums as required, my benefits may be cancelled, and I will be responsible for any paid claims.

Print Name:

Signature:

Date:

Employee ID (10 digit):

Email Address:

Office of Human Resources | Benefits Design & Management

Page 4 of 4

Coverage effective on/after Jan. 1, 2016