University of Puget Sound Flexible Benefits Plan
2016 Dependent Demographics and Benefits Enrollment
Name: ________________________
Department: _________________
Birth Date: _____________
Instructions: Complete all pages of this form, print, sign, date and submit to Human Resources. If you do not turn in
these forms within 30 days of your date of hire, your 2016 enrollment will automatically default to the High Deductible
HRA medical plan for yourself only. You will not be enrolled in the dental plan and you will not be able to sign up for a
Health Flexible Spending Account or Dependent Care Flexible Spending Account. Your next opportunity to make changes
will be during fall 2016 open enrollment unless you experience a qualifying status change.
If you are enrolling your spouse, domestic partner or child of a domestic partner on a benefit, you must complete the
Affidavit of Marriage or Domestic Partnership Form. Submit a Unum Life/AD&D Beneficiary Designation Form for your
University provided Life and AD&D insurance as well as any voluntary life, AD&D and/or disability insurance you may
elect.
Dependent Child Demographic Information. We are gathering demographic information about the dependent
children of faculty and staff so we may accurately estimate future budget needs related to the university’s education
benefits program. Please list below information about your dependent children under age 19 (including your own
children and/or the children of your spouse/domestic partner, if applicable), or check the statement below the box.
Dependent Child’s Full Name
☐
Date of Birth
(mm/dd/yyyy format)
Gender
(M/F)
I have no dependent children under age 26 to report, including my partner’s children (if applicable).
Flexible Benefits Election. Let us know which benefits you would like to be enrolled in. In addition to submitting this
Dependent Demographics and Benefits Enrollment Form, please complete a 2016 Health Care Benefits Enrollment
Form in its entirety.
MEDICAL (PREMERA BLUE CROSS)
Premera Group #1003592, Class A001
High-Deductible HRA Plan
Your Selection
Subscriber (NO COST TO YOU)
Monthly Cost
$ 0
Subscriber & Spouse/Partner
$ 624
☐
Subscriber & Child(ren)
$ 248
☐
Subscriber & Family
$ 830
☐
☐
Waiving medical coverage because I have coverage elsewhere
$ 0
☐
__________________________________________________________________________________________________________
VOLUNTARY DENTAL (PREMERA BLUE CROSS)
Premera Group #1003592, Class A001
Monthly Cost
Your Selection
Subscriber
$ 56
☐
Subscriber & Spouse/Partner
$112
☐
Subscriber & Child(ren)
$127
☐
Subscriber & Family
$183
☐
Waiving dental coverage
$ 0
☐
__________________________________________________________________________________________________________
VOLUNTARY LIFE INSURANCE (UNUM)
Policy #217151
What you are electing is additional life insurance, above the $25,000 the university is already purchasing for you. Monthly rates
are based on your age as of January 1, 2016. Following your initial election opportunity, you may increase your election by only
one tier each year during open enrollment. An election change is not allowed due to a mid-year status change. To calculate your
monthly premiums, see the Voluntary Life and AD&D Rates document.
☐$0
☐$10,000
☐$25,000
☐$50,000
☐$100,000
☐$150,000
☐$175,000
VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE (UNUM)
Policy #217151
What you are electing is additional voluntary AD&D insurance, above the $25,000 the university is already purchasing for you. You
may elect up to $300,000 for yourself and spouse/partner, and up to $20,000 for your child(ren). Spouse/partner/child elections
may not be greater than your election. An election change is not allowed due to a mid-year status change. To calculate your
monthly premiums, see the Voluntary Life and AD&D Rates document. Enter amount in thousands or leave blank if waiving.
Subscriber
Spouse/Partner
Child(ren) Up to Age 26
$
$
$
,000
,000
,000
VOLUNTARY SHORT-TERM DISABILITY INSURANCE (UNUM)
Policy #217151
The monthly rate is based on your salary and your age. To calculate your monthly premiums, see the Short-Term Disability Rates
document. An election change is not allowed due to a mid-year status change. Future election will not be guaranteed.
☐Elect
☐Waive
Flexible Spending Account Participation. Let us know below if you want to participate in a Health Care Flexible
Spending Account and/or Dependent Care Flexible Spending Account. These accounts will be administered by Navia
Benefit Solutions. Please indicate below if you plan to participate in one or both plans and complete the Navia
Flexible Spending Arrangement Enrollment/Direct Deposit Form.
HEALTH CARE FLEXIBLE SPENDING ACCOUNT (HFSA) Navia Benefit Solutions
You may elect up to $2,550 per calendar year ($212.50 per month when electing for 12 months). Please indicate if you plan to elect
or waive the HFSA. Complete the Navia enrollment/direct deposit form if you elect to participate in this plan.
☐Elect
☐Waive
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (DCFSA) Navia Benefit Solutions
You may elect up to $5,000 per calendar year ($416.67 per month when electing for 12 months). Please indicate if you plan to elect
or waive the HFSA. Complete the Navia enrollment/direct deposit form if you elect to participate in this plan.
☐Elect
☐Waive
Signature. Sign and date this form and submit it to Human Resources (Howarth 016, CMB #1064, or
hr@pugetsound.edu) within 30 days of your date of hire.
I have read about and understand my benefit choices. I understand the information provided to me in the flexible
benefits plan election guide and the limitations and exclusions that are described in the carrier policy/coverage
documents. I authorize the elections I have made and any paycheck deductions required to pay for my elections. I have
elected to enroll only individuals qualified to be on the university’s benefit plan. If I have elected to waive universitysponsored medical insurance, I attest that I have completed the necessary waiver. My next available opportunity to make
changes to my benefits will be during fall 2016 open enrollment unless I have a qualifying status change. Federal tax laws
require that money in a flexible spending account be paid out only to reimburse eligible expenses as allowed by the
Internal Revenue Service, and unused funds will be forfeited. Please note: It is a crime to knowingly provide false,
incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties
include imprisonment, fines, and denial of insurance benefits.
Signature ____________________________________________________
Date ____________________________
University of Puget Sound
2016 Health Care Benefits Enrollment Form
Name: _____________________________________________
Hire/rehire date (if within the last 3 months): _____________
Mailing address: ______________________________________________________________________________________________
Home phone #: ______________________________________
ENROLLMENT
Enrollment/Status Change Date:
Enter the actual date of the event you check below (e.g. date
of marriage, date dependent gains/loses coverage; changes
made during annual open enrollment should say 1/1/2016)
Work phone #: ______________________________________
Benefit Coverage Effective Date
(to be entered by a Benefits
Representative):
__________
__________
Enrollment/Change Reason: ☐Annual Open Enrollment
☐New Hire
☐Rehire
☐*Birth/Adoption
☐Loss/gain of other coverage under another employer’s plan ☐Part-time to full-time or entered eligible class
☐Change in your/spouse’s/child’s place of residence
☐Change in number of your dependents (other than birth/adoption)
☐Eligibility or loss of eligibility for Medicaid or CHIP
☐Enrollment in or loss of Medicare coverage
☐Change in your legal marital status or domestic partnership including death of your spouse/partner
☐Other
Please specify: ____________________________________________________________________________________
*Adding a newborn to your plan: For birth dates on the 1st – 16th of the month, new benefit premium goes into effect the 1st of the
birth month. Otherwise, the new premium will be effective the 1st of the month following the birth. If premiums have been missed,
they will be deducted on the next available paycheck.
Check the medical plan in which you are enrolling:
☐High Deductible HRA
☐Waiving university medical plan (Complete waiver declaration on page 2)
List all family members, even if you are not enrolling them on benefits. We use this information to help us project future costs of the
university’s education benefits program. Please use your legal name as it appears in your employment record. For family members
enrolled on benefits, dependent names on medical / dental ID cards will appear exactly as you indicate below.
Name
You:
Social
Security
Number
Relationship to Child
(“DP” means
“Domestic Partner”)
N/A
Spouse:
N/A
Partner:
Child:
Child:
Child:
Child:
☐
☐
☐
☐
☐
☐
☐
☐
N/A
My/spouse’s child
DP’s child
My/spouse’s child
DP’s child
My/spouse’s child
DP’s child
My/spouse’s child
DP’s child
Gender
☐ Male
☐ Female
☐ Male
☐ Female
☐ Male
☐ Female
☐ Male
☐ Female
☐ Male
☐ Female
☐ Male
☐ Female
☐ Male
☐ Female
Birthdate
MM/DD/YYYY
Enrolling
in
Medical
☐ Yes
☐No
☐ Yes
☐No
☐ Yes
☐No
☐ Yes
☐No
☐ Yes
☐No
☐ Yes
☐No
☐ Yes
☐No
Enrolling
in
Dental
☐ Yes
☐No
☐ Yes
☐No
☐ Yes
☐No
☐ Yes
☐No
☐ Yes
☐No
☐ Yes
☐No
☐ Yes
☐No
Medical & Dental Carrier: Premera Blue Cross, PO Box 327, Seattle, WA 98111
FORM #UPS –Enrollment Form - 2016
Page 1 of 2
University of Puget Sound
2016 Health Care Benefits Enrollment Form
WAIVER DECLARATION (Required if you are waiving medical coverage) I attest that I have the following medical coverage:
Name of family member who holds group coverage
____________________________________________________________
Name of family member’s employer
_____________________________________________________________
Name of insurance company
_____________________________________________________________
OR
Name of Health Benefit Exchange plan
_____________________________________________________________
MEDICARE INFORMATION (if applicable):
If you are covered by Medicare, you must provide the following:
Medicare number _____________________________
Effective date of Part A_________________________
Part B___________________________________
If your spouse is covered by Medicare, you must provide the following:
Medicare number ______________________________
Effective date of Part A_________________________
Part B___________________________________
SIGNATURE (REQUIRED)
I have read about and understand my benefit choices. I understand the information provided to me in the 2016 Open Enrollment
Guide and the limitations and exclusions that are described in the carrier policy/coverage documents. I authorize the elections I have
made and any paycheck deductions required to pay for my elections. I declare that to the best of my knowledge, all of the
information on this form is true and complete, and I have elected to enroll only individuals eligible to be on the university’s benefit
plan. If I have elected to waive university-sponsored medical insurance, I attest that I have the medical coverage noted in the Waiver
Declaration section. My next available opportunity to make changes to my benefits will be during fall 2016 open enrollment unless I
have a qualifying status change. Please note: It is a crime to knowingly provide false, incomplete, or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance
benefits.
I authorize the carrier(s) selected or its representatives to examine any physician, hospital, or insurance records concerning me or
any of my enrolled family members, as necessary for treatment, payment of claims, or operation of the health plan. I understand
that the university and its benefit carriers may collect, use, or disclose personal information about me, as described in the HIPAA
Notice of Privacy Practices section of the 2016 Open Enrollment Guide, which has been made available to me. I understand that if I
have questions or believe my privacy rights have been violated, I may contact Human Resources, University of Puget Sound, 1500 N
Warner St #1064, Tacoma, WA 98416-1064 (phone 253.879.3369).
Name (print or type) ____________________________________ Signature _____________________________________________
Date signed
_____________________________________
Medical & Dental Carrier: Premera Blue Cross, PO Box 327, Seattle, WA 98111
FORM #UPS –Enrollment Form - 2016
Page 2 of 2