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FORT BEND ISD 2015 EMPLOYEE BENEFITS ENROLLMENT/CHANGE FORM
NEW ENROLLMENT ☐
CHANGE ☐
CANCELLATION
☐
YOU MUST COMPLETE THIS ENTIRE SECTION – PLEASE PRINT IN BLUE OR BLACK INK
LAST NAME
FIRST NAME
M.I.
SOCIAL SECURITY NUMBER
EMPLOYEE ID #
STREET ADDRESS
CITY / STATE / ZIP
HOME PHONE
☐ MALE
BIRTHDATE
SCHOOL / CAMPUS / DEPARTMENT & OCCUPATION / JOB TITLE
☐ FEMALE
☐ MARRIED
☐ SINGLE
☐ DIVORCED
☐ WIDOW
☐ NEW EMPLOYEE
START DATE
☐ CURRENT EMPLOYEE
LIFE INSURANCE BENEFICIARY (Required for Basic Life Coverage) Legal appointment of Guardian is
required for minor. (Please attach sheet for additional Beneficiary)
RELATIONSHIP and % of BENEFITS
(% of Benefits MUST equal 100)
FOR OFFICE USE ONLY
EFFECTIVE DATE
FSC REASON
FIRST PAYROLL DEDUCTION
SPECIALIST INITIALS
1.
DATE
2.
These deductions are per paycheck amounts. Reference IRC Section 125 Cafeteria Plan your Medical, Dental and/or Vision premiums will be deducted on a pretax basis. Beginning with Medical Insurance and working from left to right,
decide what level of coverage you wish to purchase for each additional plan. Remember, you may select only one level of coverage for each plan. Add each selection for each selected benefit to calculate your total premium per paycheck.
This amount will be deducted from each paycheck. *Employees not wishing to participate in biometric screenings and/or health risk assessments in conjunction with Annual Enrollment will be subject to higher medical plan premiums.
*Medical (Choose ONLY One Plan)
Plan Name
Choice Plus
24 pay
Dental (Choose ONLY One Plan)
Choice Premium Tier
20 pay
24 pay
20 pay
Choice Plus HRA
24 pay
Network Access Plan or
Value Plan (circle one)
Vision
DHMO
20 pay
24 pay
20 pay
24 pay
20 pay
24 pay
20 pay
Employee Only
☐
$97.57
☐ $117.08
☐ $84.45
☐ $101.34
☐
$44.10
☐ $52.92
☐ $20.65
☐ $24.78
☐ $4.90
☐ $5.88
☐ $5.20
☐ $6.24
Employee & Spouse/
Employee + 1
☐ $322.32
☐ $386.78
☐ $261.46
☐ $313.75
☐ $149.35
☐ $179.22
☐ $41.29
☐ $49.55
☐ $8.15
☐ $9.77
☐ $8.33
☐ $9.99
Employee & Child(ren)
☐ $274.86
☐ $329.83
☐ $233.33
☐ $279.99
☐ $113.40
☐ $136.08
N/A
N/A
N/A
N/A
☐ $9.00
☐ $10.80
Employee & Family
☐ $422.81
☐ $507.37
☐ $345.88
☐ $415.05
☐ $190.60
☐ $228.72
☐ $61.93
☐ $74.32
☐ $15.17
☐ $18.20
☐ $13.70
☐ $16.44
☐ I WAIVE ALL MEDICAL COVERAGE
Voluntary Disability (Choose ONLY One Plan)
Plan Name
Employee Only
*Per $100 of Monthly Payroll
STD/LTD
STD/LTD
14-Day Elimination Period
90-Day Elimination Period
☐ I WAIVE ALLDENTAL COVERAGE
Voluntary Prepaid Legal
24 pay*
20 pay*
24 pay*
20 pay*
24 pay
20 pay
☐ $0.542
☐ $0.650
☐ $0.505
☐ $0.606
☐ $8.50
☐ $10.20
☐ I WAIVE VOLUNTARY DISABILITY COVERAGE
Note: Evidence of Insurability required for all late entrants.
☐ I WAIVE VOLUNTARY
PREPAID LEGAL
☐ I WAIVE ALL
VISION COVERAGE
SIGNATURES ARE REQUIRED ON BOTH SIDES OF THIS FORM
Employee Acknowledgement I hereby apply for the coverage now being offered to me and my
dependent(s), if any, as shown on this form. I authorize Fort Bend ISD to deduct the cost of
benefits I have elected from my pay on a pre-tax or post-tax basis as authorized by IRS Section
125. I understand that I cannot change or revoke this benefit election or compensation reduction
agreement any date prior to the next annual enrollment period unless that change or revocation
is based on and consistent with a change in my family status.
Signature
Daytime Phone
Date
FORT BEND ISD 2015 EMPLOYEE BENEFITS ENROLLMENT/CHANGE FORM
YOU MUST COMPLETE DEPENDENT INFORMATION SECTION
List All Eligible Dependents
(Last, First, M.I.)
Legal Spouse
Gender
Date of Birth
(MM/DD/YYYY)
Social Security #
Plan Elections
☐ MEDICAL
Eligible Child
Eligible Child
Eligible Child
☐ VISION
☐ DENTAL
☐ DROP
☐ MEDICAL
☐ VISION
☐ DENTAL
☐ DROP
☐ MEDICAL
☐ VISION
☐ DENTAL
☐ DROP
☐ MEDICAL
☐ VISION
☐ DENTAL
☐ DROP
Employee Acknowledgement
I understand that if I waive coverage for myself or my dependents and desire to participate in the plan at a later date, coverage may be subject to treatment as a late enrollee. I further understand that if I
waive coverage for myself or my dependents because of other health coverage, I may in the future be able to enroll myself and my dependents in the plan as long as I request enrollment within 30 days
after such coverage ends and can provide proof of loss of coverage. In addition, if a new dependent relationship forms as a result of marriage, birth, adoption or placement for adoption, I may be able to
enroll myself and my dependents provided that I request enrollment within 30 days after such marriage, birth, adoption or placement for adoption.
I hereby apply for the coverage now being offered to me and my dependent(s), if any, as shown on this form. I authorize Fort Bend Independent School District (FBISD) to deduct the cost of benefits I
have elected from my pay on a pre-tax basis (where applicable), as authorized under IRC Section 125. I declare that all entries on this form are true and complete and that any material misstatements or
failure to report information may be used as the basis for cancellation of coverage for me and my dependent(s) (if any) from the original effective date of coverage. If I am not actively at work, or my
dependents are not actively at work or are unable to engage in all the usual duties of a person of like age and gender, the effective date of all non-medical coverage will be delayed until I return to work, or
my dependent resumes usual duties. I authorize any health care professional or entity to give representatives of the health plan, or any of their designees, any and all records of information pertaining to
the medical history or services rendered to us for any administrative purposes, including evaluation of an application or claim, and for any analytical or research purposes as allowable under the Health
Insurance Portability and Accountability Act of 1996, as amended. I also authorize, on behalf of myself and any dependents, the use of a Social Security Number for purpose of identification. A
photographic copy of this authorization shall be valid as the original.
I authorize any hospital or physician to furnish my employer or their authorized representative with any information requested. Also, I hereby authorize my employer or their authorized representative to
release or obtain from any organization or person any information which may be necessary to determine benefits payable under the plan with my employer.
If elected, I am requesting STD/LTD coverage under a Group Insurance Policy offered by FBISD. This coverage will end when my employment terminates. This coverage is contributory and I authorize
FBISD to deduct the premiums from my pay. I understand that if I have previously waived coverage, I will be subject to the pre-existing condition limitation as detailed in the benefit plan contract. I also
understand that coverage will not become effective until and unless approved by Sun Life. Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent
insurance act, which is a crime and subjects a person to criminal and civil penalties.
This Employee Benefits Enrollment/Change form must be returned to the Benefits Department within 30 days of your start date or status change event.
I cannot change or revoke this benefit election or compensation reduction agreement any date prior to the next open enrollment period unless that change or revocation is based on and consistent
with a change in my family status.
EMPLOYEE SIGNATURE
Fort Bend ISD Administration Building
Benefits Department, Suite 217
16431 Lexington Blvd.
Sugar Land, TX 77479
DATE