2016 EMPLOYEE BENEFITS ENROLLMENT FORM
EMPLOYEE INFORMATION (Please Print)
Last Name
First Name, Middle Initial
Address - Street
City
Home Phone
Date of Hire
Social Security Number
State
Zip
Date of Birth
Single
Married
Are you or any dependents covered under Medicare?  Y  N


Male
Female
Divorced
Domestic Partner
If Yes for Medicare for you,
Part A:  Y  N
Part B:  Y  N
If Yes for your dependent,
Part A:  Y  N
Part B:  Y  N
Name of Medicare Dependent:
1. ENROLLMENT EVENT TYPE
 Annual Open Enrollment
 Newborn/Adoption
 Domestic Partner
 New Enrollment
 Marriage (Date ____/____/____)
 Approved Qualifying Event
Effective Date of Event: ________________
OR
Re-Hire date: _________________________
2. MEDICAL COVERAGE: Check your plan choice and coverage tier for medical coverage.
EMPLOYEE
ONLY
PLAN CHOICE
EMPLOYEE
& SPOUSE
EMPLOYEE &
DOMESTIC PARTNER
EMPLOYEE &
CHILD(REN)



Kaiser Permanente HMO #192



United Healthcare HMO*



United Healthcare PPO/HSA**
Opt Out - Decline Coverage <Complete Section “9” for Declining Medical Coverage.>
EMPLOYEE
& FAMILY






*HMO Enrollment Requires Primary Care Physician selection (Section 8).
**PPO/HSA enrollment requires separate bank acct paperwork, see HR.HSA contributions must be renewed every year.
3. DENTAL COVERAGE: Check the choice and coverage tier you elect for dental coverage.
EMPLOYEE
ONLY
EMPLOYEE &
SPOUSE
EMPLOYEE & DOMESTIC
PARTNER
EMPLOYEE &
CHILD(REN)
EMPLOYEE &
FAMILY
UHC Dental PPO





UHC Dental HMO





Opt Out - Decline Coverage

PLAN CHOICE
Give reason:  Spouse’s Coverage  Individual Coverage  Other:________
4. VISION COVERAGE: Check the choice and coverage tier you elect for vision coverage.
PLAN CHOICE
EMPLOYEE
ONLY
EMPLOYEE
& SPOUSE
EMPLOYEE
DOMESTIC PARTNER


UHC Vision
Opt Out - Decline Coverage
5. BASIC LIFE & AD&D INSURANCE: (subject to eligibility)
(1x Salary to $150,000 Benefit. Coverage provided through UNUM)
EMPLOYEE &
CHILD(REN)
EMPLOYEE &
FAMILY



 Enroll - Paid for by Saint Mary’s College – Group #143461 001
6. LONG TERM DISABILITY: (subject to eligibility)
(60% of base salary to maximum of $10,000 per month) Coverage provided through UNUM Insurance Company
 Enroll - Paid for by Saint Mary’s College – Group #143461 002
7. VOLUNTARY LIFE INSURANCE: Requires a separate enrollment form – please contact HR.
 No Changes  New Election  Changing Coverage  Opt Out – Decline Coverage Note: Paid for by Employee with post tax dollars
SAINT M ARY’S COLLEGE Benefit Enrollment Form
PAGE 2 OF 4
8. DEPENDENT PERSONAL INFORMATION: (You do not need to complete Section 8 if you are not enrolling your
dependents) Complete section for yourself and your dependent(s) or if you have changed plans or changed current
dependent status. Use a second enrollment form for additional dependents. *Affidavit of domestic partnership must be
signed. See HR for form.
Kaiser MRN (if you
have one) OR
United Healthcare
HMO Group/IPA#
Current
Other
Name (Include Last, First M/ Date of
and IPA Primary
HMO
Social Security
Coverage
Medical
and Middle Initial)
F
Birth
Number
Care Physician #
MD?
Election
Coverage
Employee:
Medical 
Dental 
Y
Y
Vision 
N
N
Spouse/Domestic Partner
Medical 
Dental 
Y
Y
Vision 
N
N
Child:
Medical
Dental
Vision
Medical
Dental
Vision
Child:






Medical 
Dental 
Vision 
Child:
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
9. DECLINING MEDICAL COVERAGE
If you are declining enrollment for yourself or your dependents (including your Spouse/DP) because of other health 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. This 31-day period is called the special enrollment period. A special enrollee is not a late enrollee. Proof of
creditable coverage from other insurance will apply towards the pre-existing limitation. In addition, you may be able to enroll yourself and
your dependents, provided that you request enrollment within 31 days after a Qualified Status Change. If you are declining enrollment for
any other reason, or if you fail to complete this form, you may be subject to certain policy or plan provisions including but not limited to
enrollment permitted only during the annual enrollment period and a 6 month pre-existing condition limitation or exclusion period upon
enrollment.
I am declining coverage for:  Myself
 My Spouse/DP
 I (we) have other medical coverage or COBRA:
Name of my (our) other carrier(s)
 My Child(ren)
 My Spouse/DP and My Child(ren)
Group Plan # _____________
 I (we) do not have other medical coverage.
I have read the above and acknowledge that I have been given the opportunity to enroll myself and (if applicable) my eligible dependents. I
also acknowledge receipt of this Notice.
Signature
Date
10. PRIOR COVERAGE INFORMATION (Needed only for those electing PPO coverage for first time)
Please fill out the following information to receive proper credit for PREVIOUS COVERAGE if immediately prior to becoming eligible for
this plan, you or your dependents were covered under any public or private health care coverage (including MediCal or Individual
coverage). According to federal law, your employer or FORMER CARRIER must provide you with a certificate that shows evidence of
your prior coverage. We reserve the right to request a copy of this certificate.
Employee:
Carrier Name
Coverage
Begin Date
Coverage End Date
Reason for Ending Coverage
Spouse/DP:_________________________________________________________________________________________
Carrier Name
Coverage
Begin Date
Coverage End Date
Reason for Ending Coverage
Child(ren): _________________________________________________________________________________________
Carrier Name
Coverage
Begin Date
Coverage End Date
Reason for Ending Coverage
List children separately if coverage is not the same for each
SAINT M ARY’S COLLEGE BENEFIT ENROLLMENT FORM
PAGE 3 OF 4
11. AUTHORIZATION: To be signed by all employees applying for either United Healthcare or Kaiser Permanente
coverage.
Kaiser Foundation Health Plan Arbitration Agreement:
I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure, and, claims
that cannot be subject to binding arbitration under governing law), any dispute between myself, my heirs, relatives,
or other associated parties on the one hand and Health Plan, its health care providers, or other associated parties on
the other hand, for alleged violation of any duty arising out of or related to membership in Health Plan, including any
claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were
improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery
of, services or items, irrespective of legal theory, must be decided by binding arbitration under California law and
not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration
proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that
the full arbitration provision is contained in the Evidence of Coverage.
Employee Signature ___________________________________________
Date _____________
Required for Kaiser Permanente HMO Plan
Authorization to Release Medical Information and Signature for United Healthcare
I authorize United HealthCare Insurance Company and its affiliates (“UnitedHealthcare and Affiliates”) to obtain, use and disclose my
medical, claim or benefit records, including any individually identifiable health information contained in these records. I understand these
records may contain information created by other persons or entities (including health care providers) as well as information regarding the
use of drug, alcohol, HIV/AIDS, mental health (other than psychotherapy notes), sexually transmitted disease and reproductive health
services. I authorize any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical
facility, health care clearinghouse, and any of their affiliates, representatives or business associates, who may be in possession of my
confidential health information, to disclose my information to UnitedHealthcare and Affiliates. I understand this authorization is voluntary
and I may refuse to sign the authorization. My refusal may, however, affect my ability to enroll in the health plan or receive benefits, if
permitted by law. I understand I may revoke this authorization at any time by notifying my UnitedHealthcare and Affiliates representative in
writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare
and Affiliates also request that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain
and use may be re-disclosed (with the exception of HIV/AIDS health information) and no longer protected by federal privacy regulations
except as prohibited by state law. This authorization, unless revoked earlier, expires 30 months after the date it is signed. I understand that
I am completing a joint life and health application and that each response must be complete and accurate. I (we) request the indicated
group medical coverage for myself and, if the plan provides, for my dependents. I authorize any required premium contributions to be
deducted from earnings. I (we) have not given the agent or any other persons any health information not included on the Request for
Coverage. I (we) understand that the HMO/insurance company(ies) is not bound by any statements I (we) have made to any agent or to
any other persons, if those statements are not written or printed on this Request for Coverage and any attachments.
Employee Signature ___________________________________________
Date _____________
Employee (Print Name)__________________________________________
Binding Arbitration
I AGREE AND UNDERSTAND THAT ANY AND ALL DISPUTES, INCLUDING CLAIMS RELATING TO THE
DELIVERY OF SERVICES UNDER THE PLAN AND CLAIMS OF MEDICAL MALPRACTICE (THAT IS, AS
TO WHETHER ANY MEDICAL SERVICES UNDER THE HEALTH PLAN WERE UNNECSSARY OR
UNAUTHORIZED OR WERE IMPROPERLY, NEGLIGENTLY OR INCOMPLETELY RENDERED), EXCEPT
FOR CLAIMS SUBJECT TO ERISA, BETWEEN MYSELF AND MY DEPENDENTS ENROLLED IN THE
PLAN (INCLUDING ANY HEIRS OR ASSIGNS) AND UNITEDHEALTHCARE OF CALIFORNIA.
UNITEDHEALTHCARE OR ANY OF ITS PARENTS, SUBSIDIARIES OR AFFILIATES, SHALL BE
DETERMINED BY SUBMISSION TO BINDING ABRITRTION. ANY SUCH DISPUTE WILL NOT BE
RESOLVED BY A LAWSUIT OR RESORT TO COURT PROCESS, EXCEPT AS THE FEDERAL
ARBITRATION ACT PROVIDES FOR JUDICAL REVIEW OF ARBITRATION PROCEEDINGS. ALL
PARTIES TO THIS AGREEMENT ARE GIVING UP THEIR CONSTITUTIONAL RIGHTS TO HAVE ANY
SUCH DISPUTE DECIDED IN A COURT OF LAW BEFORE A JURY AND INSTEAD ARE ACCEPTING THE
USE OF BINDING ARBITRATION.
Employee Signature ___________________________________________
Employee (Print Name)__________________________________________
Date _____________
SAINT M ARY’S COLLEGE BENEFIT ENROLLMENT FORM
PAGE 4 OF 4
12. AUTHORIZATION
UNUM Insurance Company Authorization





I hereby apply for the group benefit(s) that I have chosen above.
I understand that I must meet eligibility requirements for all coverage’s that I have chosen above.
I understand that my dependent(s) cannot be enrolled for a coverage unless I am enrolled for that coverage.
I agree that my employer may deduct premiums from my pay if they are required for the above coverage I have chosen.
Any person who with intent to defraud or knowing that he/she is facilitating a fraud against the insurer, submits an application or
files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Applicable to all carriers
I wish to make the choices indicated on this form and authorize Saint Mary’s College to make any necessary pre-tax or after-tax deductions,
current or future. I understand that pre-tax contributions will slightly impact my social security contributions. I certify that the information on
this form is complete and accurate. If for any reason I fail to complete a new enrollment form each plan year, the elections shown on this
form for my medical, dental and vision will remain unchanged, although the cost may change. In order to continue in the HSA a new
election form is required each plan year. If changes occur during the year that affect this information, I will notify Human Resources within
30 days of the change. My payroll deductions may change based on my tenure with Saint Mary’s College and age (Basic Life/Voluntary Life
only).
I understand that a copy of this form will be made available at my request and that it will be as valid as the original. I declare that the
information I have completed on this enrollment form is complete and true. I understand an agent or broker cannot guarantee coverage,
revise rates, benefits, or provisions without written approval from the carriers listed on this form.
Employee Signature
Date
13. BASIC LIFE BENEFICIARY DESIGNATION: (Unless otherwise specified, payment will be made to the primary
beneficiary who survives the insured; if none, by all contingent beneficiaries who survive. If more than 1 beneficiary is
named, enter a % for each. If no percentage is shown, equal shares are assumed. The right to change the beneficiary is
reserved unless otherwise noted).
If you have designated a minor child(ren) as your beneficiary, you must complete the Uniform Transfers to Minors Act form. If
you are not naming an individual or individuals as a beneficiary, check one of the following.
 Estate of Insured  Revocable or Irrevocable Trust (Enter name of Trustee, name of Trust/complete date of Trust.)
 Trustee Under Insured’s Will (If choosing this option DO NOT enter additional names in the Primary Beneficiary field.)
Primary 1 (Last, First, Initial)
Relationship
Date of Birth
Address of Primary Beneficiary (Street, City, State, Zip Code
Percentage:
Primary 2 (Last, First, Initial)
Date of Birth
Relationship
Address of Primary Beneficiary (Street, City, State, Zip Code
Percentage:
Secondary Beneficiary – Second to receive payment (optional)
Contingent 1 (Last, First, Initial)
Relationship
Date of Birth
Address of Primary Beneficiary (Street, City, State, Zip Code
Percentage:
Human Resource Use Only
Coverage Effective Date:
BNDS Form 
Sent to Carriers Date: