BENEFITS CHOICES I New Team Members – TECO Energy
Healthcare Enrollment Form
STEP ONE: Review the Benefit Choices Booklet, Cost Estimator Tool and Summary Plan
Descriptions to help you fully evaluate your health plan options.
STEP TWO: If adding spouse or dependent(s), review the Dependent Eligibility Verification
Requirements to help you provide the appropriate proof of eligibility.
STEP THREE: Complete the forms and submit with the appropriate proof of eligibility
document no later than 30 days after your hire date. (You are required to submit the
Healthcare Enrollment Form even if you are waiving coverage.)
STEP FOUR: Keep a copy of your completed enrollment forms.
COMPLETED FORMS MUST BE SUBMITTED TO:
Prior to your New Team Member Orientation:
TECO Energy, Inc.
Attn: Recruitment and Staffing – Plaza 2
P. O. Box 111
Tampa, FL 33601-0111
Fax number: 813-228-4644 or 34644
Email: slreyes@tecoenergy.com
Following your New Team Member Orientation:
TECO Energy, Inc.
Attn: Healthcare Dept. – Plaza 4
P. O. Box 111
Tampa, FL 33601-0111
Fax number:813-314-4257 or 24257
Email: benefits@tecoenergy.com
BENEFITS CHOICES I New Team Members – TECO Energy
Healthcare Enrollment Form
TEAM MEMBER NAME
TEAM MEMBER ID NO.
ADDRESS
CITY
WORK LOCATION/ EXTENSION
ST
CELL PHONE
ZIP
HOME PHONE
PLEASE REVIEW ALL MATERIALS PROVIDED AND INDICATE YOUR BENEFIT CHOICES BY MARKING AN “X”
BY EACH APPROPRIATE PLAN. This form must be submitted no later than 30 days after your hire date. If this
form is not received, you will be automatically enrolled in the Aetna Choice POS II with an HRA, employee
coverage only.
1. Please check only if you wish to waive your coverage options: If you choose to waive medical coverage with the company,
please provide proof that you are covered under another group health plan. Please attach a copy of your insurance ID card with this form
as proof of other coverage.
____ I wish to waive my medical coverage option.
I wish to waive my vision coverage
____ I wish to waive my dental coverage option.
2. Please make your healthcare plan selections below:
MEDICAL PLAN OPTIONS:
DENTAL PLAN OPTIONS:
______Aetna Choice POS II with an HRA
______Aetna PPO Dental
______Aetna Choice POS II with an HSA
______Aetna Exclusive Provider Plan (EPP)
VISION PLAN OPTION:
______Aetna Vision Preferred
3. DEPENDENT ELECTION
Since dependent elections are made separately for medical, dental and vision, please check the appropriate add or drop
box for each plan.
Note: If you add your spouse and/or dependent(s) to your healthcare coverage, please refer to the dependent eligibility requirements.
Supporting documentation must be submitted along with this form to confirm dependent enrollment.
Name
Relation
(Self, Spouse,
Daughter, Son)
Medical
Birth
Date
Dental
Vision
SSN
Add
Drop
Add
Drop
Add
Drop
PAYROLL REDUCTION AND/OR WAIVER AUTHORIZATION FOR MEDICAL/DENTAL COVERAGE
I hereby authorize the company to reduce my salary by the necessary contribution for coverage. I understand that these coverage
elections may not be changed until the next calendar year unless my family status changes in accordance with IRS rules. If I have waived
coverage, I understand I will not be eligible to enroll for any medical, dental and/or vision coverage unless my family status changes or
during the annual Open Enrollment period.
_________________________________________________________
TEAM MEMBER SIGNATURE
____________________________
DATE
Dependent Eligibility
Verification Requirements
Team members must provide documentation that validates their spouse’s/dependent’s
age/relationship in order to participate in the TECO Energy-sponsored healthcare benefits.
The following provides the steps toward meeting the healthcare benefit spouse/dependent
eligibility requirements.
STEP
ONE
STEP
TWO
STEP
THREE
Read the definition of spouse and/or dependent(s) on the next
page. If your spouse and/or dependent(s) meet the definition,
then continue reading about the Dependent Eligibility
Verification requirements.
Determine whether or not you have the documentation
available to you. If you do, make copies (do not provide
originals) and return with your Healthcare Enrollment Form to
the Healthcare Department.
If you do not have access to the needed documentation,
such as birth and marriage certificates, you can start with the
National Center for Health Statistics:
www.cdc.gov/nchs/howto/w2w/w2welcom.htm or
www.vitalrec.com. If you need a copy of your federal tax
return, you can obtain one free of charge by visiting
www.irs.gov/taxtopics/tc156.html?portlet=1. It may take a few
weeks to obtain the documentation.
DEPENDENT ELIGIBILITY VERIFICATON REQUIREMENTS
TECO Energy Spouse Definition
A person to whom you are legally married given that your marriage is recognized by the domestic or foreign jurisdiction in
which it took place so long as he/she is not covered as a team member under TECO Energy’s plan.
Required documentation for proof of eligibility: (One of the following)

Marriage certificate will ONLY be accepted if the date of marriage occurred in the current year. It must contain
the following information: name of the team member, name of the spouse, the date of marriage and certifier’s
signature.


or
Joint federal tax return. Last year’s federal tax return containing: name of team member and spouse (married
indicated). Black out financial information. Must be signed by team member, spouse and tax preparer. If filed
online, must have the electronic postmark certificate.
Both spouses’ federal tax return if filing separately. Provide last year’s federal tax returns for team member
and spouse. Tax returns should clearly list names of team member/spouse (married filing separately indicated)
and black out financial information. Must be signed by team member/spouse and tax preparer. If filed online,
must have the electronic postmark certificate.
Child(ren)
All of the following until the end of the year they reach age 26:
a)
b)
c)
d)
e)
A natural child
A step child
A legally adopted child or a child legally placed for adoption
A child by permanent legal guardianship
A grandchild, who is an IRS-recognized dependent until reaching 18 months (legal guardianship must be
submitted to TECO Energy after the child turns 18 months – the parents of the child do not reside in the same
residence as the team member)
Coverage for children ends at the end of the year when the covered child reaches his or her 26th birthday.
Coverage may continue beyond the age of 26 for an IRS-recognized dependent child, who is incapable of self-sustaining
employment because of mental or physical disability, as long as the child remains totally disabled and does not marry.
Required documentation for proof of eligibility: (One of the following)

Birth certificate showing the relationship with the team member and/or spouse. Birth certification must contain
the following information: name of the team member and/or spouse, name of the child and the date of birth.
Alternative forms of documentation allowed are: hospital birth records, naturalization certificate (if born outside
the U.S.) or consular report of birth abroad.

Adoption paperwork reflecting that the team member or spouse is the child’s permanent legal guardian. Court
order must state that the team member or spouse is the child’s legal guardian and contain the following
information: name of the legal guardian (team member or spouse), child’s date of birth, name of the child and
judge’s signature.

Court order reflecting that the team member or spouse is the child’s permanent legal guardian and contain the
following information: name of the legal guardian (team member or spouse), child’s date of birth, name of the
child and judge’s signature.

Divorce decree, court order, or Qualified Medical Child Support Order (QMSCO) reflecting that the team
member or spouse is legally responsible for providing health coverage for the child. This must contain: name of
the parent, name of the child, child’s date of birth and judge’s signature.
Plus, if 26 or older

In addition to satisfying the requirements listed above, children 26 or older must also provide:
o A signed letter from physician indicating the date of disability.
o A copy of an originally submitted “Incapacitated Child Form” or “Disabled Children Form” proving physical or
mental incapacity, making the child incapable of self-support.
BENEFITS CHOICES I New Team Members – TECO Energy
ENROLLMENT FORM
PAYFLEX HEALTH SAVINGS ACCOUNT (HSA)
TEAM MEMBER NAME
TEAM MEMBER ID NO.
ADDRESS
WORK LOCATION/ EXTENSION
CITY
CELL PHONE
ST
ZIP
HOME PHONE
HEATH SAVINGS ACCOUNT (HSA)
Annual contribution*
$______________________________
TOTAL ANNUAL HEALTH SAVINGS ACCOUNT CONTRIBUTION
Catch-up contribution*
$______________________________
*A combination of yours and TECO Energy’s contributions cannot exceed IRS limitations. If you are age 55 to
65, you can contribute up to $1,000 more in catch-up contributions. Maximums should be calculated based on
the number of months you are enrolled in the HSA for the current plan year. Refer to the Benefit Choices
Booklet for the current year individual and family annual maximums.
_______________________________________________________________________________
Please read the statement below. Sign and date this form.
I authorize the deduction of the amount designated above from my salary each month, over the course of 24
pay periods or amount remaining in current plan year, not to exceed the IRS annual limitations.
I understand that if I am under age 65 and withdraw money to pay for non-qualified expenses, I will pay income
tax associated with the expenses and a 20 percent penalty.
I am covered under a high deductible health plan (HDHP) and have no other health coverage. I am not enrolled
in Medicare and cannot be claimed as a dependent for tax return purposes.
It is my responsibility to determine whether contributions to my HSA exceed the maximum annual contribution
limit. I understand that if contributions to this HSA exceed the limit, I must notify PayFlex of the excess amount.
It is also my responsibility to request the withdrawal from my HSA of the excess contributions and any net
income attributable to it
I understand these funds should only be used for expenses incurred for my dependent(s) who meet the
requirements for qualified dependents of the tax law.
I have read and agree to the Custodial Agreement and the Fee Schedule.
____________________________________________________
TEAM MEMBER SIGNATURE
_____________________________
DATE
BENEFITS CHOICES I New Team Members – TECO Energy
ENROLLMENT FORM
LIMITED PURPOSE HEALTHCARE FLEXIBLE SPENDING ACCOUNT (HSA)
TEAM MEMBER NAME
TEAM MEMBER ID NO.
ADDRESS
WORK LOCATION/ EXTENSION
CITY
CELL PHONE
ST
ZIP
HOME PHONE
LIMITED PURPOSE HEALTHCARE FLEXIBLE SPENDING ACCOUNT (HSA)
Annual contribution*
$______________________________
*IRS annual contribution amounts: $120 minimum; $2,500 maximum
Limited Purpose Healthcare Flexible Spending Account dollars should only be used for qualified dental and
vision expenses. When deductible is met on medical plan (Choice POS II with an HSA), then Healthcare
Flexible Spending Account (HCFSA) becomes “Standard” and can be used for all other qualified HCFSA
expenses.
_______________________________________________________________________________
Please read the statement below. Sign and date this form.
I authorize the deduction of the amount designated above from my salary each month, over the course of 24
pay periods or amount remaining in the current plan year, not to exceed the IRS annual limitations.
I understand the amount deducted from my pay and not used for eligible health care expenses incurred in the
same plan year will be forfeited in accordance with IRS regulations. All expenses must occur in the current
plan year; however, reimbursement requests can be submitted to PayFlex through March 31 of the following
plan year.
I am aware that the Limited Purpose Healthcare Flexible Spending Account does not include a debit card. All
reimbursements are administered by completing and submitting the PayFlex Flexible Spending Account
Reimbursement Form. Sufficient documentation will be required to substantiate expenses.
I also understand this authorization is irrevocable until the next election period unless I have a change in my
family status.
IRS regulations require you to re-enroll in Healthcare Flexible Spending Accounts annually. This enrollment is
only for the current plan year.
____________________________________________________
TEAM MEMBER SIGNATURE
_____________________________
DATE
BENEFITS CHOICES I New Team Members – TECO Energy
SUPPLEMENTAL LIFE INSURANCE I ENROLLMENT FORM
Policyholder: TECO Energy, Inc. Underwritten by The Prudential Insurance Company of America
TEAM MEMBER NAME_________________________________________________________
 FULL-TIME
 PART-TIME
 MARRIED
 SINGLE
DATE OF BIRTH_____________________ TEAM MEMBER ID NO. _______________________ ANNUAL EARNINGS $______________
HOME ADDRESS_______________________________________________________________________________________
STREET
APT. #
CITY
STATE
ZIP
_____________________________________________________________________________________________________________________
COUNTY OF RESIDENCE
COUNTY OF EMPLOYMENT
DATE OF ENROLLMENT
PLEASE COMPLETE THE FOLLOWING FOR ADDITIONAL LIFE INSURANCE, UP TO 4 TIMES YOUR ANNUAL BASE SALARY. THE MAXIMUM AMOUNT OF
COMBINED (BASIC & SUPPLEMENTAL) LIFE INSURANCE IS $2.5 MILLION. EVIDENCE OF INSURABILITY WILL BE REQUIRED IF THE BASIC AND
SUPPLEMENTAL COMBINED EXCEEDS $1 MILLION OR IF YOUR FORM IS RECEIVED 30 DAYS AFTER YOUR DATE OF EMPLOYMENT.
Have you smoked a cigarette, cigar, used a pipe or chewing tobacco, nicotine chewing gum or snuff during the 12months prior to
today’s date?
 Yes  No
Select the amount of insurance based on your annual salary rounded to the next higher $1,000, if not already an even multiple. See
rate calculation on next page.
1 x $______
1 & 1/2 x $______
2 x $______
3 x $______
4 x $______
Coverage for spouse cannot exceed 50% of team member’s coverage.
Spouse Coverage:
 $10,000 $2.21/Month
 $25,000 $5.52/Month
Monthly Premium $__________
 $50,000 $11.04/Month
__________________________________________________________________________________________________________
Spouse Name: Last
First
MI
Date Of Birth
SSN
(mm/dd/year)
FOR YOUR DEPENDENTS/CHILDREN, YOU MAY CHOOSE ONE OF THE FOLLOWING COVERAGE OPTIONS: $5,000 OR $10,000. DEPENDENT LIFE INSURANCE: MONTHLY
LIFE RATES ARE SHOWN FOR THE TOTAL VOLUME SELECTED, NO MULTIPLICATION IS REQUIRED. DEPENDENT COVERAGE IS ONLY AVAILABLE TO: Child(ren). All of
the following until the end of the year they reach age 26: a natural child; a step child; a legally adopted child or a child legally placed for adoption; a child
by permanent legal guardianship; and a grandchild who is an IRS-recognized dependent until reaching 18 months (legal guardianship must be submitted
to TECO Energy after the child turns 18 months--the parents of the child do not reside at the same residence). Coverage for children ends at the end of
the year when the covered child reaches his/her 26th birthday. Coverage may continue indefinitely beyond age 26 for an IRS-recognized dependent
child, who is incapable of self-sustaining employment because of mental or physical disability, as long as the child remains totally disabled and does not
marry. THE TEAM MEMBER IS AUTOMATICALLY THE BENEFICIARY FOR DEPENDENT COVERAGE.
 $5,000 $1.10/Month
Child(ren) Coverage:
 $10,000 $2.20/Month
Child Name
Last
First
MI
______
______
______
______
______
______
______
______
_____
______
______
______
Date of Birth
Relationship
SSN
______
MAKE SURE TO CHECK ALL THAT APPLY. COVERAGES ARE IN ACCORDANCE WITH THE PROVISIONS OF THE POLICY AND THE POLICY WILL GOVERN
DISCREPANCIES.
The optional group life insurance has been offered to me, and I have decided to:
1) ____ Request the coverage for which I am or may become eligible for under the group policies.
2) ____ Authorize any required deductions from my earnings.
3) ____ Use the beneficiary designation form to specify to whom benefits are payable in the event of my death.
I understand that to be eligible, I must be a permanent and actively at-work team member.
________________________________________________________________
Team Member Signature
______________________________
Date
TEAM MEMBER SUPPLEMENTAL LIFE INSURANCE RATES
(Rates are per $1,000/coverage)
Age
Smoker Rate
*Non-Smoker Rate
< – 25
$0.112
$0.048
25 – 29
$0.128
$0.072
30 – 34
$0.168
$0.080
35 – 39
$0.184
$0.088
40 – 44
$0.208
$0.096
45 – 49
$0.312
$0.128
50 – 54
$0.480
$0.208
55 – 59
$0.904
$0.376
60 – 64
$1.392
$0.608
65 – 69
$2.680
$1.088
70 +
$4.340
$3.700
*You must be tobacco-free for the past 12 months to qualify for non-smoker rates.
Rate Calculation Example
26 year-old non-smoker
$85,000 annual salary *4 = $340,000 (life insurance coverage amount)
Rates are per $1,000 of coverage
($340,000/$1,000)
340 x 0.072 = $24.48 per month
BENEFITS CHOICES I New Team Members – TECO Energy
GROUP LIFE INSURANCE BENFICIARY DESIGNATION
FEMALE
MALE
MARITAL STATUS
MARRIED
SINGLE
TEAM MEMBER NAME: LAST, FIRST, MI
TEAM MEMNER ID NO.
DATE OF BIRTH
HOME ADDRESS: STREET
ANNUAL EARNINGS
APT.#
CITY
STATE
ZIP
BENEFICIARY INFORMATION: If you indicate more than one person as your primary beneficiary, benefits will be
equally divided among them, unless otherwise specified by you. The same applies to contingent beneficiaries. A
contingent beneficiary will receive benefits if the primary beneficiary is deceased.
If only one beneficiary section is completed and you are enrolled in other coverage listed below, all levels of life
insurance will be paid the same.
*Percentage (%) must be whole numbers totaling 100% (example: 33%, 33%, 34% = 100%)
BASIC LIFE INSURANCE (Paid by TECO Energy)
Primary or
Contingent
[Check one]
Full Name
Social Security
Number
Relationship
*Share %
Full Name
Social Security
Number
Relationship
*Share %
SUPPLEMENTAL LIFE
Primary or
Contingent
[Check one]
Team Member Signature
Date
Form is not complete unless signed and dated. Completed form will replace previous beneficiary designations.
YOU MAY NAME DIFFERENT BENEFICIARIES FOR EACH LEVEL OF COVERAGE OR ONE
BENEFICIARY FOR ALL LEVELS OF COVERAGE.
BENEFICIARY means a person or persons you name to receive death benefits.
EXAMPLES OF COMMON BENEFICIARY DESIGNATIONS AND HOW THEY SHOULD BE USED
Type of Beneficiary Designation
Sample Wording to be Used
Primary Beneficiary and Contingent
 Primary, John Doe, spouse, if living 100%
 Contingent, Sam Jones, friend 100%
Primary Beneficiary and Contingent
“two contingent Beneficiaries”
 Primary, John Doe, Spouse, if living 100%
 Contingent, Sam Jones, friend 50%
 Contingent, Sally Jones, friend 50%
Two Beneficiaries with Equal Shares
“two primary Beneficiaries and two contingent
Beneficiaries”
 Primary, John Doe, father 50%
 Primary, Ann Doe, mother 50 %
 Contingent, Sam Jones, friend 50%
 Contingent, Sally Jones, friend 50%
Trust
Name of Trust, date, and address
Minors
Insured Estate
If a minor is named as Beneficiary and the insurer
dies, the monies are placed in a Retained Asset
(Interest Bearing) Account until the minor is 18 years
old.
A letter of administration assigned by the court will be
required.
Federal Law requires a married participant to name his or her spouse as primary Beneficiary for Employee
Stock Ownership and 401(k) plans. If another person is named as Beneficiary (in place of spouse), signature
of spouse’s approval is required and form must be notarized.
You may name anyone as Beneficiary for your Life Insurance, unless there is a court decree requiring you to
name or retain someone as Beneficiary. Please furnish a copy of any Court Decree concerning Beneficiaries
for your Life Insurance plans.
If there is no named Beneficiary, or none survive you, the benefit will be paid in equal shares to the first
surviving class in the following order:
1.
2.
3.
4.
5.
your spouse;
your children;
your parents;
your brothers and sisters; and
your estate.