JACKSONVILLE UNIVERSITY
Effective Date: __________________
Flexible Benefits Election Form
Adm / Fac / Staff (Please Circle)
If you are applying for insurance coverage, please complete this form, which may be in addition to the insurance carrier enrollment form.
New Hire
Type of Enrollment:
Lifestyle Change/
Special Enrollment Event
Eligibility Change
Annual Enrollment
Employee Name:
Last
Gender:
First
Date of Birth:
Male
Middle
SSN #:
Female
Home /Work Phone
County
Email Address:
Mailing Address:
City
Street
Marital Status:
Single
Date of Hire:
State
Divorced
Zip
Widowed
Separated
Married
DEPENDENT INFORMATION
Name of Dependent
Rel.
Social Security #
DOB
Gender
Coverage
Sp
Med
Dental
Vision
Ch
Med
Dental
Vision
Ch
Med
Dental
Vision
Ch
Med
Dental
Vision
Ch
Med
Dental
Vision
Rates Per Pay Period
1. MEDICAL INSURANCE
Premiums Per Pay Period
I elect HMO
BCBSFL
I elect Blue Options PPO
41-002
I elect Blue Options HDHP
3559-001
3160-004 / 3161-003
Employee
$ 21.50
Employee
$ 57.50
Employee
$ 0.00
Employee + Spouse
$257.00
Employee + Spouse
$290.00
Employee + Spouse
$ 66.00
Employee + Child(ren) $211.50
Employee + Child(ren) $240.50
Employee + Child(ren)
Employee + Family
Employee + Family
Employee + Family
$482.00
$521.50
TD BANK
HMO - Primary Provider –
$ 36.00
$217.50
$
HEALTH SAVINGS ACCOUNT (HSA)
Only Available With HDHP 3160/3161
Full Name ___________________
Individual (2014 Maximum $3300)
$______ / Pay $______ / Year
$
ID # (10-12 digits)
_________________________
Family
$______/ Pay $______ / Year
$
(2014 Maximum $6550)
Catch Up Contribution (Age 55+) *
$______ / Pay $______ / Year
Existing Patient
* Maximum Catch Up $1000 / Year
I decline/cancel Medical Coverage
TOTAL HSA CONTRIBUTION
$
REASON:
CALCULATION OF PARTIAL YEAR MAXIMUM FOR HSA DUE TO DISENROLLMENT OR TURN AGE 65
$$ / Month
# of Months Available
$$ x # of Months
= Max for year
Individual Max 3300 / 12 = 275 / Month
Family Max 6550 / 12 = 545.83 / Month
Catch Up (Age 55) 1000 / 12 = 83.34 / Month
NOTE: If your spouse also has a Health Savings Account the sum of the two HSA’s may not exceed the maximum family
limit plus catch up, if applicable.
2. DENTAL INSURANCE
Florida Combined Life / BCBSFL
I elect Co-pay Plan
Employee
I elect Trad Plan
$6.64
Employee
$17.13
Employee + Spouse
$19.48
Employee + Spouse
$37.24
Employee + Child(ren)
$20.75
Employee + Child(ren)
$41.30
Employee + Family
$31.29
Employee + Family
$61.41
$
Previous Carrier Name:
Eff Date:
Term Date:
I decline/cancel Dental Coverage at this time
1
01/03/2014
JU Universal Enroll Election /2014 Benefits Orientation/ desktop
Name:
Eff. Date
3. VISION INSURANCE
Page 2
COMPBENEFITS
I elect Vision Coverage
Employee $3.25
Employee + Family $9.30
$
I decline/cancel Vision Coverage
4. BASIC LIFE/AD&D INSURANCE
STANDARD
1 x Salary to $150,000
Annual Salary:$______________
5. SUPPLEMENTAL LIFE INSURANCE
Employer Paid
$
EE______________
$
SPOUSE _________
$
CHILD:
STANDARD
Employee Coverage
Rate Chart - Supplemental Coverage Employee /
Spouse
Rate
Age Group Rate
Age Group
.06
<30
.47
50-54
.07
30-34
.77
55-59
.09
35-39
1.1
60-64
.16
40-44
1.90
65-69 Vol at 65%
.30
45-49
2.84
70 + Vol at 50%
1x, 2x or 3x Salary up to $400,000
Guarantee Issue: $150,000
Multiply, then round to the nearest $1,000
Employee Annual Salary:$___________ X_____ =
Coverage Amount:$______________
Examples:
Age 25, Annual Salary $22,100
Spouse Coverage
(Salary / 1,000) x
$5,000 increments to $150,000
Not to exceed 50% of employee supplemental coverage.
Guarantee Issue: $25,000
Spouse Name:___________________
Spouse DOB:______________ Volume:____________
Child Life Insurance
$
Rate, then divide by 2
(22.1) x .06 = $1.33 or $ .66 per pay period.
Age 65 at 2x Salary of $22,100 – Volume at 65%
$44,200 rounded to $45,000 $45,000 x .65 = $29,250
$29,250 / 1000 = $29.25 $29.25 x 1.90 = $55.58 or
$27.79 per pay period.
$2,000 - $.15
$6,000 - $.45
$4,000 - $.30
$8,000 - $.60
$10,000 - $.75
Employee
Spouse
Note: Supplemental
Coverage of EE is
required
I decline/cancel Supplemental Life
Coverage:
6. SHORT TERM DISABILITY 60% of Salary Limited to
$500/week ((Annual Salary/1000) x .3171)= cost per pp
I elect Short Term Disability coverage
Child
STANDARD
Max Cost $13.75 / pp at $43,300 Annual Salary
I decline Short Term Disability coverage
7. LONG TERM DISABILITY
$
STANDARD
60% of basic monthly earnings up to $10,000 per month
after 180 days of disability
Annual Salary: $______________
$
Employer Paid
8. FLEXIBLE SPENDING ACCOUNT MAX MED $2500 / DEP $5000
Annual $ / 12 mos x eligible months = Prorated Annual For Example:
MIN $600 Prorated
AMERIFLEX
$2500 / 12 = 208.33 x 6 mos =$1250
I elect Medical: Annual $__ /12 mos x __mos elig= Annual $___________
I decline/cancel Medical FSA
$
I elect Dependent Care: Annual$__/12 mos x mos elig =Annual $_______
I decline/cancel DCA
$
ALL STATE – Accident / Cancer / Heart / Universal Life
9. VOLUNTARY PRODUCTS
Coverage Type: ____________________
Coverage Amount: _______________________
$
10. Retirement Plan: Eligible for Matching? _____ SRA?___ Application Given:___________
I acknowledge I am eligible for the Retirement Annuity as of ___/___/___ and the supplemental plan immediately. I
have received an SPD for each plan and fee disclosures for all plans and understand I may view these documents
and updates of these documents on the JU website.
Name;
2
Signature:
Date: /
01/03/2014
/
JU Universal Enroll Election /2014 Benefits Orientation/ desktop
Name:
Eff. Date
Page 3
10. LIFE INSURANCE BENEFICIARY DESIGNATIONS – For JU Paid, Supplemental ,Dependent and Voluntary Plans
Beneficiary’s Name
SSN If Available
Relationship
Address
Percentage
Primary
Contingent
TERMS AND CONDITIONS
Only for Section 125 Plans
 I cannot change or revoke this compensation reduction agreement at any time during the plan year unless I have a change in family status, or job status for employee or
employee’s spouse, as stated in the plan document.
 The plan administrator may reduce or cancel my compensation reduction or otherwise modify this agreement in the event he believes it advisable in order to satisfy
certain provision of the internal revenue code.
 If my required contributions for the elected benefits are increased or decreased while this agreement remains in effect, my compensation reduction will automatically be
adjusted to reflect that increase or decrease.
 The reduction in my cash compensation reduction under this agreement shall be in addition to any reductions under other agreements of benefit plans.
 My social security benefits may be slightly reduced as a result of my election.
 This agreement will automatically terminate if the plan is terminated or discontinued, or if I cease to receive compensation from the company which, before reduction
hereunder, is at least equal to the amount of that reduction.
 Prior to the first day of each plan year, I will be offered the opportunity to change my benefits election for the following plan year. If I do not complete and return a new
election form at that time, I will be treated as having elected to continue my benefit coverage then in effect for the new plan year. In addition, this compensation
reduction agreement will continue by its terms in the amount of the required contribution for the benefit option.
EMPLOYEE AGREEMENT
Authorization and agreement to participate in the Pre-Tax Benefit:
I have read the information describing the benefit plan and agree to abide by the terms. I recognize I must submit a Change in Family Status Form to Jacksonville University
before I can change my initial election. I further understand that I cannot change my election during the policy year unless I have a change to my Family Status as described
above; however, I may change my election at the next annual enrollment period.
I have received the information explaining the Jacksonville University benefit program. I hereby make elections for the plan year and understand that my election cannot be
changed before the next open enrollment period unless I have a family status change. By my signature below, I authorize deductions to my pay resulting from my benefit
choices.
I represent the information provided is true and complete to the best of my knowledge. I understand the provision of any false information on this application may result in
corrective action.
Signature:
Date
WAIVER OF PARTICIPATION IN ALL BENEFITS
All of the benefits that I am eligible for have been communicated to me in the new hire orientation and/or annual open enrollment meeting. At this time I
will not elect any of the employee benefits that I am eligible for with the exception of the employer paid benefits.
I do understand that by declining I will not be able to enroll in any of the benefit programs until the next annual open enrollment meeting and I may be
subject to waiting periods on some levels of coverage or I may enroll before the next open enrollment meeting if I have a change in my family’s status or
become a dependent.
WAIVE PARTICIPATION - NEW HIRE ORIENTATION
SIGN:
DATE:
WAIVE PARTICIPATION – ANNUAL OPEN ENROLLMENT MEETING
SIGN:
DATE:
HIPAA SPECIAL ENROLLMENT RIGHTS
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health
plan coverage, you may be able to enroll yourself and your dependents in this plan if you and your dependents lose eligibility for that other
coverage (or if the employer stops contributing towards your or your dependents' other coverage). However, you must request enrollment
within 30 days after your or your dependents' other coverage ends.
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll
yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for
adoption.
To request special enrollment or obtain more information, contact the Human Resources Department at (904) 256-7708.
(10/23/2013)
3
01/03/2014
JU Universal Enroll Election /2014 Benefits Orientation/ desktop