Congratulations and Welcome to University Medical Center of Southern Nevada! **PER DIEM** (Non-Benefitted or Temporary Position) New Hire Processing New Hire Processing What to Expect Your Online New Hire Packet is available for you to complete prior to new hire processing. New Hire Processing consists of the following: Completing your Online Background Check through Certiphi (instructions sent to you via email); Completing your Drug Screen; Completing your Employee Health Assessment with Enterprise; Completing and printing your required online forms; Returning all required online forms to Human Resources on your scheduled processing date.* If forms are not completed when you arrive for new hire processing, this will delay your start date. *You will be scheduled for New Hire Processing as soon as Human Resources obtain confirmation you have cleared your Drug Test and Background Check. A Human Resources Representative will contact you and schedule New Hire Processing. New Hire Processing is held on Tuesday and 7KXUVGD\ (excluding Holidays). Morning and afternoon sessions are available. New hire processing generally requireV1 hour of your time and is UNPAID. New Hire Processing Location: UMC Human Resources Office 901 Rancho Lane, Ste. 160 Las Vegas, NV 89106 (IIHFWLYHSURFHVVLQJZLOOEH7XHVGD\7KXUVGD\$0±$0DQG30±30 PLEASE NOTE ALL OF THE FOLLOWING: DRUG TESTING – You have 48 hours from the time of the offer being extended to complete your drug test. BACKGROUND CHECK PROCESSING - You have 48 hours from the time of the offer being extended to complete your online Background Screening Form. Your Background Check may take up to 10 business days to clear. EMPLOYEE HEALTH ASSESSMENT - You must contact Enterprise Physicals -Employee Health IMMEDIATELY to schedule your Pre-Employment Physical at (702) 383-3660. Human Resources will be notified once you have cleared. You will not be scheduled for New Employee Orientation until you have cleared your Employee Health Assessment. New Employee Orientation will be three (3) full days. Some medical positions require additional time and your Human Resources Representive will provide you with specifics at time of processing. New Employee On-Boarding Forms (PER DIEM NEW HIRES) You must complete, print and return the following forms to Human Resources for processing. (If forms are not completed when you arrive for processing, you may be rescheduled which could delay your start date.) Human Resources Information Sheet Pre-Employment Drug/Alcohol Testing Consent Form Form I-9, Employment Eligibility Verification (Print and return Page 7) Form W-4 (Employee Withholding Allowance Certificate) UMC Beneficiary Designation Form UMC Direct Deposit Authorization Form - Bring a voided check or preprinted direct deposit authorization from your bank reflecting the account number and routing number complete with last name, first name, middle initial and indicate checking or savings account. Please choose from the banking facility listed. If it’s an out of state account, mark “other”, write name of bank and write the routing number. Sign and date. (Do not attach deposit slips) FICA Alternative and the Deferred Compensation Plan Basic Facts about FICA Alternative and the Deferred Compensation Plan-OBRA (For your records only) Beneficiary Designation/Name & Address Change – 457 and 401(a) Complete Employee and Beneficiary section including dates of birth, Social Security number(s), relationship, percentage of benefit and your signature. (total percentage for all designated beneficiaries must equal 100% and Social Security numbers are required) NV PERS Retiree Re-employment Notification Non-PERS Eligible Position (If applicable) UMC Parking Permit Form Remember your “New Hire Packet” must be completed prior to your scheduled new hire processing date. If you have any questions regarding the new hire processing or required pre-employment documents, please feel free to contact the HR Analyst at 383-2230. UNIVERSITY MEDICAL CENTER HUMAN RESOURCES INFORMATION SHEET (PLEASE PRINT) POSITION OFFERED: _________________________________________________ SSN:__________________________________ Are you currently receiving Nevada PERS retirement benefits? Y N (If yes, you will be required to complete the Retiree Reemployment Notification Non-PERS Eligible Position form at time of processing). NAME: _______________________________________________ First Middle Initial Last PRIMARY CONTACT NO: ( ) _____________________ SECONDARY CONTACT NO: ( ) _____________________ CURRENT ADDRESS: STREET ADDRESS MARITAL STATUS: M S Apt. # CITY, STATE DATE OF BIRTH: ___________________ ZIP GENDER: _______ ETHNICITY - Please choose one (W) White: (Not of Hispanic origin) All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East. (B) Black: (Not of Hispanic origin) All persons having origins in any of the Black racial groups of Africa. (H) Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race. (A) Asian or Pacific Islander: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Sub continent, or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Phillippine Islands and Samoa. (I) American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. VETERANS STATUS: ______ 1. Special Disabled (Please indicate by number only) 2. Vietnam Era Veteran 3. Other eligible veteran 4. Non qualifying veteran or no military service PLEASE CHOOSE FROM ONE OF THE FOLLOWING: US CITIZEN RESIDENT ALIEN ALIEN AUTHORIZED TO WORK PERSON TO CONTACT IN CASE OF EMERGENCY: NAME: RELATIONSHIP: ADDRESS: STREET ADDRESS PHONE NUMBER: ( Apt. # CITY, STATE ZIP ) _________________________ EMPLOYEE SIGNATURE: HR USE ONLY Form #08-62 (11/08) DATE: Background Check: Completed Required Basic Computer Skills: Completed Required Drug Test: Completed Required Completed Required Employee Health Assessment: PRE-EMPLOYMENT DRUG & ALCOHOL TESTING CONSENT NMU00823 (02/06/14) Page 1 of 1 I understand that pre-employment drug and alcohol testing is a condition of employment with the University Medical Center of Southern Nevada (UMC). I hereby consent to submit to a drug and alcohol test and authorize Quest Laboratories or another testing laboratory designated by UMC to perform the tests deemed necessary to determine the presence or absence of drugs and alcohol in my urine. I authorize the designated laboratory to release my test results to UMC and, if necessary, to a Medical Review Officer selected by UMC to evaluate my test results. I understand that the Medical Review Officer may request proof that I am taking a controlled substance pursuant to a lawful prescription issued in my name. If requested, I must provide such proof within 72 hours. I further understand that the Medical Review Officer will release my final test results to UMC. I understand that a positive result may render me ineligible for hire at UMC. I agree to hold UMC harmless from any liability arising in whole or part from the collection of specimens, testing, and use of the information from said testing in connection with UMC’s consideration of my application for employment. I further understand that a positive result may be reported to governmental agencies and/or boards as mandated by law. Applicant Name (print): Date: Applicant Signature: ORIGINAL: UMC Human Resources COPY: Applicant Form W-4 (2014) Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2014 expires February 17, 2015. See Pub. 505, Tax Withholding and Estimated Tax. Note. If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,000 and includes more than $350 of unearned income (for example, interest and dividends). Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: • Is age 65 or older, • Is blind, or • Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return. The exceptions do not apply to supplemental wages greater than $1,000,000. Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations. Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages. Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity iincome, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P. Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details. Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2014. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married). Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4. Personal Allowances Worksheet (Keep for your records.) A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A • You are single and have only one job; or Enter “1” if: B • You are married, have only one job, and your spouse does not work; or . . . • Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less. Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F (Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information. • If your total income will be less than $65,000 ($95,000 if married), enter “2” for each eligible child; then less “1” if you have three to six eligible children or less “2” if you have seven or more eligible children. G • If your total income will be between $65,000 and $84,000 ($95,000 and $119,000 if married), enter “1” for each eligible child . . . ▶ Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) H { B C D E F G H For accuracy, complete all worksheets that apply. } { • If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions and Adjustments Worksheet on page 2. • If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld. • If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below. Separate here and give Form W-4 to your employer. Keep the top part for your records. Form W-4 Department of the Treasury Internal Revenue Service 1 Employee's Withholding Allowance Certificate OMB No. 1545-0074 ▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS. Your first name and middle initial 2 Last name Home address (number and street or rural route) 3 Single Married 2014 Your social security number Married, but withhold at higher Single rate. Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box. City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card, check here. You must call 1-800-772-1213 for a replacement card. ▶ 5 6 7 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $ I claim exemption from withholding for 2014, and I certify that I meet both of the following conditions for exemption. • Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and • This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7 Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete. Employee’s signature (This form is not valid unless you sign it.) 8 Date ▶ ▶ Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) For Privacy Act and Paperwork Reduction Act Notice, see page 2. 9 Office code (optional) Cat. No. 10220Q 10 Employer identification number (EIN) Form W-4 (2014) Page 2 Form W-4 (2014) Deductions and Adjustments Worksheet Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income. Enter an estimate of your 2014 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state 1 and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1950) of your income, and miscellaneous deductions. For 2014, you may have to reduce your itemized deductions if your income is over $305,050 and you are married filing jointly or are a qualifying widow(er); $279,650 if you are head of household; $254,200 if you are single and not head of household or a qualifying widow(er); or $152,525 if you are married filing separately. See Pub. 505 for details . . . . $12,400 if married filing jointly or qualifying widow(er) 2 Enter: $9,100 if head of household . . . . . . . . . . . $6,200 if single or married filing separately 3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 4 Enter an estimate of your 2014 adjustments to income and any additional standard deduction (see Pub. 505) Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to 5 Withholding Allowances for 2014 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . { 6 7 8 9 10 } Enter an estimate of your 2014 nonwage income (such as dividends or interest) . . . . . . . . Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . Divide the amount on line 7 by $3,950 and enter the result here. Drop any fraction . . . . . . . Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 1 $ 2 $ 3 4 $ $ 5 6 7 8 9 $ $ $ 10 Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.) Note. Use this worksheet only if the instructions under line H on page 1 direct you here. Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 1 2 3 Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill. 4 5 6 7 8 9 Enter the number from line 2 of this worksheet . . . . . . . . . . 4 Enter the number from line 1 of this worksheet . . . . . . . . . . 5 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . Divide line 8 by the number of pay periods remaining in 2014. For example, divide by 25 if you are paid every two weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2014. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck Table 1 Married Filing Jointly If wages from LOWEST paying job are— Enter on line 2 above 6 7 8 $ $ 9 $ Table 2 All Others If wages from LOWEST paying job are— Married Filing Jointly Enter on line 2 above $0 - $6,000 0 $0 - $6,000 0 1 6,001 - 13,000 6,001 - 16,000 1 2 13,001 - 24,000 16,001 - 25,000 2 3 24,001 - 26,000 25,001 - 34,000 3 4 26,001 - 33,000 34,001 - 43,000 4 5 33,001 - 43,000 43,001 - 70,000 5 6 43,001 - 49,000 70,001 - 85,000 6 7 49,001 - 60,000 85,001 - 110,000 7 8 60,001 - 75,000 110,001 - 125,000 8 9 75,001 - 80,000 125,001 - 140,000 9 10 80,001 - 100,000 140,001 and over 10 100,001 - 115,000 11 12 115,001 - 130,000 13 130,001 - 140,000 14 140,001 - 150,000 15 150,001 and over Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. If wages from HIGHEST paying job are— $0 74,001 130,001 200,001 355,001 400,001 - $74,000 - 130,000 - 200,000 - 355,000 - 400,000 and over Enter on line 7 above $590 990 1,110 1,300 1,380 1,560 All Others If wages from HIGHEST paying job are— $0 - $37,000 37,001 - 80,000 80,001 - 175,000 175,001 - 385,000 385,001 and over Enter on line 7 above $590 990 1,110 1,300 1,560 You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103. The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return. If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return. BENEFICIARY DESIGNATION Under NRS 281.155 NRS 281.155 allows you to designate a beneficiary to receive your final paycheck in the event you expire while employed at University Medical Center. The final payment will be available to your beneficiary rather than tying the funds up in the probate of your estate. This law is intended to make the amount of your last paycheck immediately available to your beneficiary. If you wish to designate a beneficiary for this purpose, complete this form and submit it to Human Resources. All information will be kept confidential. PRNR Employee Name (First Name, MI, Last Name) I hereby designate (First Name, MI, Last Name) as beneficiary under the provisions of NRS 281.155 SSN: (required) Address: City/State/Zip Code: Telephone 1: Telephone 2: Relationship: Name of Contingent: (if above predeceases the employee) SSN: (First Name, MI, Last Name) (required) Address: City/State/Zip Code: Telephone 1: Telephone 2: Relationship: Signature Date: MAIN BANK PAYROLL DIRECT DEPOSIT AUTHORIZATION Name: Last First MI PRNR (new hires, use SSN): Bank Account Number: DIRECT DEPOSIT TYPE OF ACCOUNT: (Please check one) Checking Account- Attach a voided check or pre-printed direct deposit authorization from bank. Savings Account- Attach pre-printed documentation reflecting account number (please do not attach deposit slips) MAIN BANKING FACILITY FOR ABOVE ACCOUNT: (Please check one) Routing Number (for Human Resources’ use only) Bank of America Chase Bank CitiBank West Clark County Credit Union Greater Nevada Credit Union Nevada State Bank One Nevada Credit Union Silver State Schools Federal Credit Union US Bank Wells Fargo Bank WestStar Credit Union Other: 122400724 322271627 321070007 322484113 321280143 122400779 322484401 322484265 121201694 321270742 322484634 I authorize UMC to deposit my entire payroll check directly to the above selected main banking facility. I understand that credit to my account is not guaranteed on payroll Friday. I fully understand that I am responsible for verifying the credit to my account and that UMC is not responsible for any transfer delays or related overdraft fees/charges by the bank. Final checks (termination/separation) will be issued as a negotiable check and not automatically deposited to your bank account by UMC. Signature Date ***DIRECT DEPOSIT STARTS IMMEDIATELY*** BASIC FACTS ABOUT FICA ALTERNATIVE AND THE DEFERRED COMPENSATION PLAN As a per diem or temporary employee of the University Medical Center of Southern Nevada, you are required to participate in UMC’s FICA Alternative Deferred Compensation Plan (“Plan”). The Plan is an alternative to Social Security coverage as permitted by the federal Omnibus Budget Reconciliation Act of 1990 (“OBRA”). As a FICA alternative employee, you are not subject to tax on compensation under the Old Age, Survivors and Disability Income portion of FICA. You will be subject to the Medicare portion of FICA. MANDATORY CONTRIBUTIONS: As a FICA alternative employee, 7.5% of your gross compensation per pay period must be contributed to the Plan. Your contributions are made on a tax deferred basis, and are not subject to federal or state income tax. You will be taxed on the value of your contributions (including any earnings) when you receive a distribution of your benefits from the Plan. Unless your status as a FICA alternative employee changes, you may not stop or reduce mandatory contributions to the Plan. No additional contributions are permitted under the Plan. ENROLLMENT: As a per diem or temporary employee, you are automatically enrolled in the plan and there is nothing you need to do, except complete the beneficiary form, and ensure that you have designated a beneficiary. Retain a copy for your personal files, and then forward the completed original form to Human Resources Trauma 5th Floor, for delivery to The Hartford. FUNDING OPTION: The Plan must limit its investment options to one that provides a fixed rate of return. Your contributions are automatically invested in the General (declared rate) account with Hartford that provides stability of principle. DISTRIBUTIONS Distribution of your Plan benefits can only be made upon your: • Severance from employment • Death • Attainment of age 70 ½, regardless of employment status A severance from employment occurs when you are no longer employed at UMC, either voluntarily or involuntarily. A leave of absence is not a severance of employment. If your employment status changes from per diem or temporary to full-time or part-time employment, you may be eligible to transfer your benefits under the FICA Alternative Plan to the UMC Deferred Compensation Plan. Otherwise, the Plan does not provide for withdrawals while you are still employed at UMC. When you sever employment, or upon your death, your benefits will be payable to you, or your beneficiary, in accordance with the payment options provided under the Plan. You may elect to receive your distribution upon severance of employment or defer payment to a later date. Your benefits will become taxable when received. If you have any further questions, please call The Hartford customer service line at 1.800.255.2464. PLEASE COMPLETE AND RETURN THE BENEFICIARY FORM IMMEDIATELY. Enrollment Record- Part-time 457 Deferred Compensation Fax No. : 816-701-8005 SECTION I. Group Number: Employer: 61236-5-1 SECTION II. Social Security Number: UMC OBRA Plan Date of Birth: Sex (M or F): Employee Name: Last, First, M.I. Mailing Address: City: State: Zip: Home Phone: Work Phone: Ext: SECTION III. Deferral % Deferral Frequency Bi-weekly Allocation 100% General Account 7.5 % SECTION IV. BENEFICIARY DESIGNATION I designate the following person(s) as my beneficiary(ies) under the Plan . Please see page 2 for examples. Primary Beneficiary(ies) Relationship % Contingent Beneficiary(ies) Relationship % SECTION V. NOTIFICATION OF ACCEPTANCE I understand and agree to the provisions contained in my Employer’s Deferred Compensation Plan. Together with my heirs, successors, and assigns, I will hold harmless my Employer from any liability hereunder for all acts performed in good faith, including those related to the investment of deferred amounts and/or my Employer’s investment preference(s) under my Employer’s Deferred Compensation Plan. I understand that 100% of my deferrals will be deposited in the General Account. Signed in the State of on Date Participant Signature Authorized Plan Sponsor Signature Registered Representative Signature Printed Name of Registered Representative Registered Representative Tax ID/Producer Code Rev. 8.14 Date Beneficiary Designation Please complete the Beneficiary Designation including name, Social Security number, relationship, and percentage of death benefit (totaling 100%). Married residents of community property states may want to seek legal advice if naming a non-spouse Primary Beneficiary. Type of Beneficiary: Examples of Designations: One Beneficiary Jane Doe, wife, 100% Two or more Primary Beneficiaries, equally among the survivors John Doe, son, 33% Carol Smith, daughter, 33% Mark Doe, son 34% or equally among the survivors Two or more Primary Beneficiaries, with their share to their children John Doe, son, 33% Carol Smith, daughter, 33% Mark Doe, son 34% per stirpes Primary and Contingent Beneficiaries Jane Doe, wife, 100% if living; otherwise children equally among the survivors per stirpes either or Participant’s Estate Participant’s Estate Trustee Jane Doe, trustee under trust agreement* dated... * Date of the execution of the trust agreement or a copy of the trust agreement must be provided. Full Disclosure Statement Arkansas “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.” Colorado “It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Services.” District of Columbia “WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.” Florida “Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.” Kentucky “Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.” Louisiana “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.” Maine “It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.” New Jersey “Any person who includes any false or misleading information on an application for an insurance policy, is subject to criminal and civil penalties.” New Mexico “Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.” Ohio “Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, is guilty of insurance fraud.” Oklahoma “WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.” Oregon “Any person who knowingly, and with INTENT TO DEFRAUD or solicit another to defraud an insurer (1) by submitting an application, or (2) by filing a claim containing a false statement as to any MATERIAL FACT, MAY BE violating state law.” Pennsylvania “Any person who knowingly and with intent to defraud any insurer files an application or claim containing any false, incomplete or misleading information shall, upon conviction be subject to imprisonment for up to seven years and payment of a fine of up to $15,000.” Tennessee “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.” Rev. 8.14 page 2 of 2 Public Employees’ Retirement System of Nevada 693 W. Nye Lane, Carson City, NV 89703 - (775) 687-4200 - Fax (775) 687-5131 5820 S. Eastern Avenue, Suite 220, Las Vegas, NV 89119 - (702) 486-3900 – Fax (702) 678-6934 7455 W. Washington Avenue, Suite 150, Las Vegas, NV 89128 – (702) 486-3900 – Fax (702) 304-0697 Toll Free Number 1-866-473-7768 www.nvpers.org Retiree Reemployment Notification Non-PERS Eligible Position PERS retirees are prohibited from reemployment with a Nevada public employer except as provided by NRS 286.520. This provision allows a retiree to receive a monthly PERS benefit while reemployed with a Nevada public employer if the retiree has been retired for a minimum of 90 days and the position does not require reenrollment back into PERS. Eligibility for PERS enrollment is based on the type of position in which the retiree has been hired. In some cases, the retiree is limited on the amount of hours he or she may work in either a fiscal or school year in order to avoid the suspension of the monthly benefit and reenrollment into the system. In all cases, retirees reemployed with a Nevada public employer are limited in the amount they can earn in a fiscal year. Contact the PERS office for the earnings limitation currently in effect. Employer Notification We have hired the below PERS retiree into a position that does not require their reenrollment back into PERS. We agree to monitor the earnings and hours worked by this retiree in order to avoid a violation of PERS’ reemployment rules. We agree to notify PERS within 10 days in the event the retiree exceeds the fiscal year earnings limitation or is in a position in which the work hours require reenrollment into the system. Retiree Name:___________________________________________________________ Social Security Number:___________________________________________________ Position Title:_________________________________Hire Date:__________________ _____________________________ Liaison Officer/Signature Authority ____________________________ Date _____________________________ _____________________________ Agency Name Agency Number ***************************************************************************************** Retiree Notification I have accepted a position with a Nevada public employer that does not require my reenrollment back into PERS. I agree to monitor my work hours and earnings in this position in order to avoid a violation of PERS’ reemployment rules. I agree to notify PERS within 10 days if I exceed the fiscal year earnings limitation or if my work hours require that I be reenrolled back into the system. ________________________________________________________________________ Retiree Signature Date PERS Use Only Date received Rev. 03/11 1800 W. Charleston Blvd. NV Las Vegas 702-383-2000 (Optional): 89102
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