Annual Benefits Election 2012

(1)

Human Resources 300 S. Broadway St. Louis, MO 63102

Medical Insurance

Type or Print in ink – corrections or whiteouts must be initialed

Human Resources MUST receive election forms no later than 5 p.m. Thursday, April 19, 2012

Last Name _ First Name M.I._

Address ___ Date Employed Full-Time

City Annual Salary ____

State Zip Position ____________________________

Home Phone ( ) Work Location _______________

Social Security # _ Work Phone ( ) ____________

Marital Status: Employee Category: ( ) Administrator ( ) Faculty ( ) Professional ( ) Classified/Physical Plant

Is your spouse a full time College employee?

UnitedHealthcare “Standard Plan”

REQUIRED FAMILY INFORMATION – Please list yourself and each dependent to be enrolled

Name Relationship Sex Birth Date Social Security Number

__________________ Self _ ___________________

______________ _ _ ___________________

______________ _ _ __________________

_________________________

________________________

_____________________

____________________

______

_____________

________________________

Employee contributions for medical insurance premiums will be collected through payroll deduction under the College’s Salary Reduction Plan. This pre-tax payment of premiums is permissible under Section 125 of the Internal Revenue Code. IRS regulations and the College’s Section 125 Plan require that you MAY NOT DROP, ADD TO or CHANGE YOUR ELECTED COVERAGE until the College’s next scheduled annual election unless you have a change in family status which includes: marriage; divorce, death of a spouse or child; birth, adoption or placement for adoption of a child;

change in the spouse’s employment status or loss of coverage due to a change in the spouse’s employment; unpaid leave of absence or a change from full-time to part-time status or vice versa of the employee or spouse; a substantial premium increase or other related family status events that may be provided by applicable law. You have 31 days from the date of your change in family status to make any enrollment changes to your current insurance; otherwise, changes cannot be made until the next annual election. Election forms are available from Human Resources and the business office. Your election form must be received by Human Resources within the 31-day time limit.

SIGNATURE __________________ DATE

Your signature authorizes the College to take payroll deductions for your share of the premium costs for the insurance coverage you elected and acknowledgment that you understand that the deduction for medical is a part of the College’s Salary Reduction Plan. Your signature also authorizes your physician, hospital or other health care providers to furnish the insurance company with medical information about you and any eligible dependent listed above.

Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person who files an application for insurance or a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any factual material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

(2)

St. Louis, MO 63102

Dental Insurance

Human Resources MUST receive election forms no later than 5 p.m. Thursday, April 19, 2012

Last Name: _________ First M.I.

Address ______ Date Employed Full-Time

City _ Position ______

State _Zip Work Location_____________________

Home Phone ( ) _ Work Phone ( ) __________

Social Security # _________________________

Marital Status:

Is your spouse a full time College employee?

Dental Insurance (Complete Required Family Information Below)

 Aetna Dental – PPO

Adding New Dependent(s) Please list name(s)

Canceling Dependent(s) Please list name(s)

__

 Dental Source – HMO –

New Dental Source participants must choose a dentist from the provider list and enter the dental office ID# below

Adding New Dependent(s) Please list name(s) Canceling Dependent(s) Please list name(s)

__

REQUIRED FAMILY INFORMATION – Please list yourself and each dependent to be enrolled

Name Relationship Sex Birth Date Social Security Number Dental Source Office ID #

1

^st

Choice 2

^nd

Choice

________________________ Self _ _ _

________________ _ _ _

Employee contributions for dental insurance premiums are collected through payroll deduction under the College’s Salary Reduction Plan. This pre-tax payment of premiums is permissible under Section 125 of the Internal Revenue Code. IRS regulations and the College’s Section 125 Plan require that you MAY NOT DROP, ADD TO or CHANGE YOUR ELECTED COVERAGE until the College’s next scheduled annual election unless you have a change in family status which includes: marriage; divorce, death of a spouse or child; birth, adoption or placement for adoption of a child; change in the spouse’s employment status or loss of coverage due to a change in the spouse’s employment; unpaid leave of absence or a change from full-time to part-time status or vice versa of the employee or spouse;

a substantial premium increase or other related family status events that may be provided by applicable law. You have 31 days from the date of your change in family status to make any enrollment changes to your current insurance; otherwise, changes cannot be made until the next annual election. Election forms are available from Human Resources and the business office. Your election form must be received by Human Resources within the 31-day time limit.

SIGNATURE ________________________ DATE _

Your signature authorizes the College to take payroll deductions for your share of the premium costs for the insurance coverage you elected and acknowledgment that you understand that the deduction for dental are a part of the College’s Salary Reduction Plan. Your signature also authorizes your physician, hospital or other health care providers to furnish the insurance company with medical information about you and any eligible dependent listed above.

(3)

Vision and Short Term Disability

Human Resources MUST receive election forms no later than 5 p.m. Thursday, April 19, 2012

Last Name: ______________ First M.I.

Address ___________ Date Employed Full-Time

City ____ Annual Salary

State_____________ Zip _ Position __________________________________

Home Phone ( ) Work Location_______

Social Security # Work Phone ( ) __

Marital Status:

Is your spouse a full time College employee?

Voluntary Short Term Disability (STD)

Vision Insurance ( Complete Required Family Information Below)

Change Coverage to

Adding New Dependent(s) Please list name(s) Canceling Dependent(s) Please list name(s)

__

REQUIRED FAMILY INFORMATION – Please list yourself and each dependent to be enrolled

Name Relationship Sex Birth Date Social Security Number

__________________ Self _ ___________________

______________ _ _ ___________________

______________ _ _ __________________

Employee contributions for vision insurance premiums will be collected through payroll deduction under the College’s Salary Reduction Plan. This pre-tax payment of premiums is permissible under Section 125 of the Internal Revenue Code. IRS regulations and the College’s Section 125 Plan require that you MAY NOT DROP, ADD TO or CHANGE YOUR ELECTED COVERAGE until the College’s next scheduled annual election unless you have a change in family status which includes: marriage; divorce, death of a spouse or child; birth, adoption or placement for adoption of a child;

SIGNATURE

___________________________________________________________________

DATE

____________________________________

Your signature authorizes the College to take payroll deductions for your share of the premium costs for the insurance coverage you elected and acknowledgment that you understand that the deduction for vision is a part of the College’s Salary Reduction Plan. Your signature also authorizes your physician, hospital or other health care providers to furnish the insurance company with medical information about you and any eligible dependent listed above.

(4)

St. Louis, MO 63102

Life/AD&D and Long Term Disability

Human Resources MUST receive election forms no later than 5 p.m. Thursday, April 19, 2012

Last Name: ______________ First M.I.

Address ___________ Date Employed Full-Time

City ____ Annual Salary

State_____________ Zip _ Position __________________________________

Home Phone ( ) Work Location_______

Social Security # Work Phone ( ) __

Marital Status:

Is your spouse a full time College employee?

Life/Accidental Death & Dismemberment – If enrolling for the first time, a Proof of Insurability form MUST be completed.

(Please Complete Designation of Beneficiary form on the back)

Change Coverage to

Adding New Dependent(s) Please list name(s) Canceling Dependent(s) Please list name(s)

____________________________________

__

Long Term Disability (LTD ) – If enrolling for the first time or increasing to 70%, a Proof of Insurability form MUST be completed.

REQUIRED FAMILY INFORMATION – Please list yourself and each dependent to be enrolled

Name Relationship Sex Birth Date Social Security Number

__________________ Self _ ___________________

______________ _ _ ___________________

______________ _ _ __________________

Employee contributions for LTD insurance premiums will be collected through payroll deduction under the College’s Salary Reduction Plan. This pre-tax payment of premiums is permissible under Section 125 of the Internal Revenue Code. IRS regulations and the College’s Section 125 Plan require that you MAY NOT DROP, ADD TO or CHANGE YOUR ELECTED COVERAGE until the College’s next scheduled annual election unless you have a change in family status which includes: marriage; divorce, death of a spouse or child; birth, adoption or placement for adoption of a child;

change in the spouse’s employment status or loss of coverage due to a change in the spouse’s employment; unpaid leave of absence or a change from full-time to part-time status or vice versa of the employee or spouse; a substantial premium increase or other related family status events that may be provided by applicable law. You have 31 days from the date of your change in family status to make any enrollment changes to your current insurance; otherwise, changes cannot be made until the next annual election. Election forms are available from Human Resourcesand the business office. Your election form must be received by Human Resources within the 31-day time limit.

SIGNATURE

__________________________________________________________________

DATE

____________________________________________

Your signature authorizes the College to take payroll deductions for your share of the premium costs for the insurance coverage you elected and acknowledgment that you understand that the deduction for vision and LTD are a part of the College’s Salary Reduction Plan. Your signature also authorizes your physician, hospital or other health care providers to furnish the insurance company with medical information about you and any eligible dependent listed above.

(5)

Life/AD&D Beneficiary Form

Human Resources MUST receive election forms no later than 5 p.m. Thursday, April 19, 2012

Last Name: ______________ First M.I.

Address ___________ Date Employed Full-Time

City ____ Annual Salary

State_____________ Zip _ Position __________________________________

Home Phone ( ) Work Location_______

Social Security # Work Phone ( ) __

BENEFICIARY DESIGNATION – LIFE/AD&D: You Are Required To Complete In Full

Complete addresses are required

Primary Beneficiary(ies) Address Relationship

____________ _

Contingent Beneficiary(ies)

Will receive benefits in case person (s)

listed above are deceased

Address Relationship

____________ _

_____

I hereby designate the above beneficiary(ies) and reserve the right to change my beneficiary(ies) at anytime without

the consent of the named beneficiary(ies).

SIGNATURE__________________ DATE:

(Full Legal Name)

Suggested Beneficiary Designations – May be used for primary and/or contingent.

Note: A married woman should be designated by her own name not Mrs. Joe Doe

 One beneficiary – Mary E. Doe, wife

 Two beneficiaries (equal amounts) – John H. and Mary E. Doe, Parents, equally or survivor

 Three or more beneficiaries (equal amounts) – John H. and Mary E. Doe, Parents, and Joan J. Doe, sister,

equally or survivor

 Unequal amounts – 75% to Mary E. Doe, wife, if living, otherwise to Jane J. Doe, mother;

25% to Jane J. Doe, mother, if living, otherwise to Mary E. Doe, wife

 To name your estate as beneficiary – write “Estate”

(6)

St. Louis, MO 63102

Voluntary Accidental Death & Dismemberment

Human Resources MUST receive election forms no later than 5 p.m. Thursday, April 19, 2012

Last Name _ First Name M.I._

Address ___ Date Employed Full-Time

City Annual Salary ____

State Zip Position ____________________________

Home Phone ( ) Work Location _______________

Social Security # _ Work Phone ( ) ____________

Marital Status: Employee Category: ( ) Administrator ( ) Faculty ( ) Professional ( ) Classified/Physical Plant

Is your spouse a full time College employee?

Voluntary Accidental Death & Dismemberment (VADD)

Indicate amount of coverage here from rate chart $____________________

Choose the level of coverage that best fits your needs... from $10,000 - $750,000

(Amounts in excess of $350,000 cannot exceed 10 times annual salary)

10,000 140,000 270,000 400,000 530,000 660,000

20,000 150,000 280,000 410,000 540,000 670,000

30,000 160,000 290,000 420,000 550,000 680,000

40,000 170,000 300,000 430,000 560,000 690,000

50,000 180,000 310,000 440,000 570,000 700,000

60,000 190,000 320,000 450,000 580,000 710,000

70,000 200,000 330,000 460,000 590,000 720,000

80,000 210,000 340,000 470,000 600,000 730,000

90,000 220,000 350,000 480,000 610,000 740,000

100,000 230,000 360,000 490,000 620,000 750,000

110,000 240,000 370,000 500,000 630,000

120,000 250,000 380,000 510,000 640,000

130,000 260,000 390,000 520,000 650,000

REQUIRED FAMILY INFORMATION – Please list yourself and each dependent to be enrolled

Name Relationship Sex Birth Date Social Security Number

__________________ Self _ ___________________

______________ _ _ ___________________

______________ _ _ __________________

Employee contributions for VADD insurance premiums will be collected through payroll deduction under the College’s Salary Reduction Plan. This pre-tax payment of premiums is permissible under Section 125 of the Internal Revenue Code. IRS regulations and the College’s Section 125 Plan require that you MAY NOT DROP, ADD TO or CHANGE YOUR ELECTED COVERAGE until the College’s next scheduled annual election unless you have a change in family status which includes: marriage; divorce, death of a spouse or child; birth, adoption or placement for adoption of a child;

SIGNATURE __________________ DATE

Your signature authorizes the College to take payroll deductions for your share of the premium costs for the insurance coverage you elected and acknowledgment that you understand that the deduction for medical and VADD are a part of the College’s Salary Reduction Plan. Your signature also authorizes your physician, hospital or other health care providers to furnish the insurance company with medical information about you and any eligible dependent listed above.

(7)

Voluntary Accidental Death & Dismemberment Beneficiary Form

Human Resources MUST receive election forms no later than 5 p.m. Thursday, April 19, 2012

Last Name _ First Name M.I._

Address ___ Date Employed Full-Time

City Annual Salary ____

State Zip Position ____________________________

Home Phone ( ) Work Location _______________

Social Security # _ Work Phone ( ) ____________

BENEFICIARY DESIGNATION – VADD: You Are Required To Complete In Full

Complete Addresses are Required

Primary Beneficiary(ies) Address Relationship

____________ _

Contingent Beneficiary(ies)

Will receive benefits in case person(s)

listed above are deceased

Address Relationship

____________ _

I hereby designate the above beneficiary (ies) and reserve the right to change my beneficiary (ies) at anytime without

the consent of the named beneficiary (ies).

SIGNATURE_________________ DATE:

(Full Legal Name)

Suggested Beneficiary Designations – May be used for primary and/or contingent.

Note: A married woman should be designated by her own name not Mrs. Joe Doe

 One beneficiary – Mary E. Doe, wife

 Two beneficiaries (equal amounts) – John H. and Mary E. Doe, Parents, equally or survivor

 Three or more beneficiaries (equal amounts) – John H. and Mary E. Doe, Parents, and Joan J. Doe, sister,

equally or survivor

 Unequal amounts – 75% to Mary E. Doe, wife, if living, otherwise to Jane J. Doe, mother;

25% to Jane J. Doe, mother, if living, otherwise to Mary E. Doe, wife

 To name your estate as beneficiary – write “Estate

Annual Benefits Election 2012

Medical Insurance

Human Resources MUST receive election forms no later than 5 p.m. Thursday, April 19, 2012

Last Name ___________________________ First Name ______________________________M.I._____

Address _____________________________ Date Employed Full-Time __________________________

City ________________________________ Annual Salary ____________________________________

State ____________ Zip ________________ Position ________________________________________

Home Phone ( ) ____________________ Work Location ___________________________________

Social Security # _____________________ Work Phone ( ) ________________________________

Marital Status: Employee Category: ( ) Administrator ( ) Faculty ( ) Professional ( ) Classified/Physical Plant

Is your spouse a full time College employee?

UnitedHealthcare “Standard Plan”

REQUIRED FAMILY INFORMATION – Please list yourself and each dependent to be enrolled

Name Relationship Sex Birth Date Social Security Number

__________________________ Self ______ _____________ _________________________

__________________________ _____________________ ______ _____________ _________________________

__________________________ _____________________ ______ _____________ ________________________

__________________________ _____________________ ______ _____________ ________________________

_________________________

________________________

_____________________

____________________

______

______

_____________

_____________

________________________

________________________

SIGNATURE ________________________________________________ DATE ______________________________

Dental Insurance

Human Resources MUST receive election forms no later than 5 p.m. Thursday, April 19, 2012

Last Name: _____________________________ First ______________________________M.I.__________

Address ________________________________ Date Employed Full-Time __________________________

City ___________________________________ Position ________________________________________

State _______________Zip ________________ Work Location___________________________________

Home Phone ( ) _______________________ Work Phone ( ) ________________________________

Social Security # _________________________

Marital Status:

Is your spouse a full time College employee?

Dental Insurance (Complete Required Family Information Below)

 Aetna Dental – PPO

Adding New Dependent(s) Please list name(s)

Canceling Dependent(s) Please list name(s)

______________________________________ ____________________________________

 Dental Source – HMO –

Adding New Dependent(s) Please list name(s) Canceling Dependent(s) Please list name(s)

__________________________________ ____________________________________

REQUIRED FAMILY INFORMATION – Please list yourself and each dependent to be enrolled

Name Relationship Sex Birth Date Social Security Number Dental Source Office ID #

1

Choice 2

Choice

__________________________ Self _____ _____________ ___________________ ________ ________

__________________________ ____________ _____ _____________ ___________________ ________ ________

__________________________ ____________ _____ _____________ ___________________ ________ ________

__________________________ ____________ _____ _____________ ___________________ ________ ________

__________________________ ____________ _____ _____________ ___________________ ________ ________

SIGNATURE ______________________________________________________ DATE _______________________________

Vision and Short Term Disability

Human Resources MUST receive election forms no later than 5 p.m. Thursday, April 19, 2012

Last Name: __________________________________ First ______________________________M.I.__________

Address _____________________________________ Date Employed Full-Time __________________________

City ________________________________________ Annual Salary____________________________________

State_____________________ Zip _______________ Position ________________________________________

Home Phone ( ) ____________________________ Work Location___________________________________

Social Security # ______________________________ Work Phone ( ) ________________________________

Marital Status:

Is your spouse a full time College employee?

Voluntary Short Term Disability (STD)

Vision Insurance ( Complete Required Family Information Below)

Change Coverage to

Adding New Dependent(s) Please list name(s) Canceling Dependent(s) Please list name(s)

__________________________________ ____________________________________

REQUIRED FAMILY INFORMATION – Please list yourself and each dependent to be enrolled

Name Relationship Sex Birth Date Social Security Number

__________________________ Self ______ _____________ _________________________

__________________________ _____________________ ______ _____________ _________________________

__________________________ _____________________ ______ _____________ ________________________

__________________________ _____________________ ______ _____________ ________________________

__________________________ _____________________ ______ _____________ ________________________

Last Name _ First Name M.I._

Address ___ Date Employed Full-Time

City Annual Salary ____

State Zip Position ____________________________

Home Phone ( ) Work Location _______________

Social Security # _ Work Phone ( ) ____________

__________________ Self _ ___________________

______________ _ _ ___________________

______________ _ _ __________________

______________ _ _ __________________

SIGNATURE __________________ DATE

Last Name: _________ First M.I.

Address ______ Date Employed Full-Time

City _ Position ______

State _Zip Work Location_____________________

Home Phone ( ) _ Work Phone ( ) __________

__

__

________________________ Self _ _ _

________________ _ _ _

________________ _ _ _

________________ _ _ _

________________ _ _ _

SIGNATURE ________________________ DATE _

Last Name: ______________ First M.I.

Address ___________ Date Employed Full-Time

City ____ Annual Salary

State_____________ Zip _ Position __________________________________

Home Phone ( ) Work Location_______

Social Security # Work Phone ( ) __

__

__________________ Self _ ___________________

______________ _ _ ___________________

______________ _ _ __________________

______________ _ _ __________________

______________ _ _ __________________

______________ _ _ __________________

Last Name: ______________ First M.I.

Address ___________ Date Employed Full-Time

City ____ Annual Salary

State_____________ Zip _ Position __________________________________

Home Phone ( ) Work Location_______

Social Security # Work Phone ( ) __

__

__________________ Self _ ___________________

______________ _ _ ___________________

______________ _ _ __________________

______________ _ _ __________________

______________ _ _ __________________

______________ _ _ __________________

Last Name: ______________ First M.I.

Address ___________ Date Employed Full-Time

City ____ Annual Salary

State_____________ Zip _ Position __________________________________

Home Phone ( ) Work Location_______

Social Security # Work Phone ( ) __