OrthoLink Benefits Enrollment Form



Benefit Enrollment/Change Form

Medical, Dental, Vision and Life Insurances

Enrollment form and documentation (if applicable) required to enroll in your benefits must be received by Benefit Services no later than your 31st calendar day of regular, benefit eligible employment.

Employees making changes to benefit coverage due to a change in family or eligible employment status must attach supporting documentation for the qualifying event. All forms must be turned in to Benefit Services within 31 calendar days from the date of the qualifying event.

Employees adding coverage for dependents must provide documentation supporting the relationship and eligibility of the dependent, including spouse or domestic partner, with the enrollment form. A list of acceptable documents is available on the Benefit Services website at .

|1. EMPLOYEE INFORMATION |Aggie ID #:       |

| Last Name |First Name |MI |Social Security # |Gender |

|      |      |      |      |Male |

| | | | |Female |

|Mailing Address (Street, City, State, Zip) |Phone Number |Date of Birth |

|      |      |      |

| New Hire       (date of hire) Late Enrollment Beneficiary Change |

| |

|Qualifying Event – supporting documentation required Date of Qualifying Event/Change in Status:       |

|Marriage Birth/Adoption Divorce Change in dependent eligibility status Gain of other Coverage |

|Loss of other Coverage Death Other       |

|2. DEPENDENT INFORMATION – List all eligible dependents |

| |

|Designate children of domestic partners by checking the DP Child box under the dependent’s gender. |

|Dependent |      |

|Male | |

|Female | |

|DP Child | |

|3. Pre-tax Premium - Available for Medical, Dental and Vision Benefits Only |

|The Pre-Tax Premium Plan is offered to all NMSU employees enrolled in the NMSU Medical, Dental and Vision plans. Once pre-tax is opted, it will automatically apply |

|to medical, dental and vision premiums.The Pre-Tax Plan allows employees to have their medical, dental and/or vision premiums (excluding domestic partner portions |

|of the premium) deducted from their salaries before income taxes are calculated. By using the pre-tax method for premium payments, employees can reduce their |

|taxable income, and through tax savings, lessen the impact of insurance costs on their spendable income. |

|Once enrollment in the Pre-Tax Premium Plan is completed, the Plan remains in effect during the employee's entire employment at NMSU: |

|unless cancelled during the annual enrollment period, or; |

|if a participant makes a mid-year election change in response to a change in status only if the election change is "on account of and corresponds with a change in |

|status that affects eligibility for coverage under an employer's plan." |

|Employees may want to consult with a tax advisor prior to making changes to the pre-tax or post-tax election. |

| YES, I will accept the opportunity to enroll in the NMSU Pre-Tax Premium Plan. I hereby authorize NMSU to deduct from my salary each pay period the amount |

|necessary to make my contributions toward payment of premiums for the NMSU Medical, Dental and Vision plans. I understand that the tax implications for the pre-tax |

|program are regulated by the IRS. I hold NMSU harmless if any damages or losses occur to me, including penalty and interest assessment by the IRS. ______________ |

|(initials) |

| NO, I decline the opportunity to enroll in the NMSU Pre-Tax Premium Plan. I understand that I may enroll later only at the time of annual enrollment held in the |

|Spring of each year with enrollment becoming effective July 1st. |

|4. VISION PLAN - Plan rates are attached I DECLINE VISION COVERAGE |

|New Enrollment Late Enrollment Change to Existing Enrollment Cancellation No Change |

| Employee | Employee/Spouse | Employee/Child(ren) | Family |HR Code: |

| | |* no spouse/DP |(Employee & Spouse/DP + child or | |

| |Employee/Partner | |children) |BCOV Date: |

| | | | | |

| | | | |DEDN Date: |

|5. MEDICAL PLAN - Plan rates are attached I DECLINE MEDICAL COVERAGE |

|New Enrollment Late Enrollment Change to Existing Enrollment Cancellation No Change |

| | Employee/Spouse | Employee + One Child | Family |HR Code: |

|Employee | | |(Employee + 2 or more) | |

| |Employee/Partner | | |BCOV Date: |

| | | | | |

| |Presbyterian HMO |Presbyterian HMO |Presbyterian HMO |DEDN Date: |

|Presbyterian HMO | | | | |

| |Presbyterian HDHP |Presbyterian HDHP |Presbyterian HDHP | |

|Presbyterian HDHP |*Optional HSA |*Optional HSA |*Optional HSA | |

|*Optional HSA | | | | |

| |Lovelace HMO |Lovelace HMO |Lovelace HMO | |

|Lovelace HMO | | | | |

| |BCBSNM PPO |BCBSNM PPO |BCBSNM PPO | |

|BCBSNM PPO | | | | |

|*Optional Health Savings Account (HSA) requires additional form for enrollment. Please visit Benefit Services Website. |

|New Enrollment--expect a delay in accessing HSA funds due to processing timelines. |

|6. DENTAL PLAN - Plan rates are attached I DECLINE DENTAL COVERAGE |

|New Enrollment Change to Existing Enrollment Cancellation No Change |

| Employee | Employee/Spouse | Employee + One Child | Family |HR Code: |

| | | |(Employee + 2 or more) | |

| |Employee/Partner | | |BCOV Date: |

| | | | | |

| | | | |DEDN Date: |

|Employee Last Name, First Name, MI |NMSU Aggie ID# |

|, | |

|7. GROUP LIFE & AD&D INSURANCE |

|I DECLINE GROUP LIFE & AD&D INSURANCE; I understand that if I choose to enroll at a later date, a health questionnaire will be required. __________ (initials) |

|New Enrollment Late Enrollment Change to Existing Enrollment Cancellation No Change |

| I ELECT [pic] |Employee coverage is equal to two (2) times basic annual earnings* rounded to the next |HR Code: |

|Cost is 25¢ per $1000 of coverage (multiplied by|$1000, maximum of $75,000 | |

|the employee’s percentage rate*) |*Earnings do not include overtime, bonuses or any other form of extra pay. |BCOV Date: |

| |I understand that if I am not actively at work on the effective date of my coverage, my| |

|*Employee contribution is based on salary. |insurance will not begin until the day I return to active work.________________ |DEDN Date: |

| |(initials) | |

| |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. | |

|8. LONG TERM DISABILITY INSURANCE |

|I DECLINE LONG TERM DISABILITY INSURANCE; I understand that if I choose to enroll at a later date, a health questionnaire will be required. ___________ (initials) |

|New Enrollment Late Enrollment Change to Existing Enrollment Cancellation No Change |

| I ELECT [pic] |I hereby request to be insured and authorize NMSU to deduct the amount I am required to|HR Code: |

|Cost is 14¢ per $100 of covered salary |pay for my share of the cost of the benefit to which I am entitled under the group | |

|(multiplied by the employee’s percentage rate*) |policy issued to NMSU. I understand that if I am not actively at work on the effective |BCOV Date: |

| |date of my coverage, my coverage will not begin until the day I return to work. | |

|*Employee contribution is based on salary. |______________ (initials) |DEDN Date: |

| |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. | |

|9. VOLUNTARY LIFE & AD&D INSURANCE |

|I DECLINE VOLUNTARY LIFE & AD&D INSURANCE, I understand that if I choose to enroll at a later date, a health questionnaire will be required. ____ ______ (initials) |

|New Enrollment Late Enrollment Change to Existing Enrollment Cancellation No Change |

| I ELECT [pic] |VOLUNTARY LIFE – required if enrolled in AD&D |HR Code: |

| |Coverage Amounts - Min $20,000 max $600,000 | |

|Employee cost is 100% of premium | | |

|Voluntary Life Cost is based on age; refer to |Requested Coverage (Check All that apply): |BCOV Date: |

|brochure for cost. |Employee Guaranteed Coverage Amount $       | |

| |Up to $200,000 | |

|AD&D Cost is based on amount elected for |Employee Additional Coverage Amount $       | |

|individual or family |Guaranteed & Additional combined cannot exceed $600,000 | |

| | |DEDN Date: |

|Guaranteed amounts are only available to new |Spouse/Partner Guaranteed Coverage Amount $       | |

|hires enrolling in the first 31 days of |Up to $50,000 – cannot exceed Employee Amount | |

|employment or employees losing other voluntary |Spouse/Partner Additional Coverage Amount $       | |

|life insurance and adding as a qualifying event |Guaranteed & Additional combined cannot exceed Employee | |

|within 31 days of loss of coverage. |Amount or $100,000, whichever is less | |

| | | |

| |Child/Children Coverage | |

| |Option 1 - $1,000 under 6 mos/$5,000 over 6 mos. | |

| |Option 2 - $2,000 under 6 mos/$10,000 over 6 mos. | |

| |ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) –required if enrolled in Voluntary Life |HR Code: |

| |Amount of election: $      | |

| |Individual Family |BCOV Date: |

| |May elect $200,000 or $250,000 or an amount between $20,000 and $150,000 in $10,000 | |

| |increments. |DEDN Date: |

|Employee Last Name, First Name, MI |NMSU Aggie ID# |

|, | |

BENEFICIARIES LISTED WILL BE FOR ALL NMSU LIFE INSURANCE POLICIES,

UNLESS SPECIFICALLY STATED OTHERWISE

|10. Primary Beneficiary Designation (attach a separate page if additional space is needed) |

|Primary Beneficiary Designation must = 100% |

|#1 Beneficiary (Last Name, First Name) |Date of Birth |Social Security # |

|      |      |      |

|Relationship |Benefit % |

|      |      |

|#2 Beneficiary (Last Name, First Name) |Date of Birth |Social Security # |

|      |      |      |

|Relationship |Benefit % |

|      |      |

|11. Contingent Beneficiary Designation (attach a separate page if additional space is needed) |

|Contingent Beneficiary Designation must = 100% |

|#1 Beneficiary (Last Name, First Name) |Date of Birth |Social Security # |

|      |      |      |

|Relationship |Benefit % |

|      |      |

|#2 Beneficiary (Last Name, First Name) |Date of Birth |Social Security # |

|      |      |      |

|Relationship |Benefit % |

|      |      |

|12. EMPLOYEE AUTHORIZATION AND SIGNATURE |

|Note to married employees: If you reside in a community property state in which life insurance is considered community property, and you name someone other than |

|your spouse as primary beneficiary, your spouse must sign the enrollment form in the space provided below. Payment of benefits may be delayed or disputed unless |

|your spouse signs. |

| |

|I hereby consent to the Primary Beneficiary designated by my spouse and understand that this consent supersedes any prior spousal consent under this plan. |

| |

|Spouse/Partner Signature: Date: |

| |

|I certify that all information supplied on this form is true to the best of my knowledge. I understand that all benefits for myself and my eligible dependents will|

|be provided in accordance with the terms of the plan(s) in which I have enrolled. I agree to abide by the terms and conditions provided in the plan(s). I |

|authorize my employer to reduce my salary in an amount necessary to pay for my benefit elections. |

|Employee Signature: Date: |

|The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic |

|information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not |

|provide any genetic information when responding to this request for medical information. “Genetic information” as defined by GINA, includes an individual’s family |

|medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received |

|genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family|

|member receiving assistive reproductive services. |

Information regarding annual enrollment cycles and late enrollment options for the benefits listed on the enrollment form is available on the Benefit Services website at . Questions regarding the benefit programs can be directed to 575-646-8000 or benefits@nmsu.edu.

Benefit Premiums

Effective January 1, 2013

*Premium Contributions for Medical, Group Life & AD&D, and Long Term Disability are shared between

NMSU and the employees based on the following salary schedule:

|Annual Salary |NMSU % |Employee % |

|$0 - $26,249 |80 |20 |

|$26,250 - $31,499 |70 |30 |

|$31,500+ |60 |40 |

Medical Premiums Per Paycheck

| Premiums for 12 month | Premiums for 9 month employees |

|employees | |

|Plan |Total Premium |Emp|Employee 30% |

| | |loy| |

| | |ee | |

| | |20%| |

| |Total Per Pay Period |Employee | |Total Per Pay Period |Employee |

| |Contribution |Pay Period Contribution | |Contribution |Pay Period Contribution |

|Employee Only |$14.50 |$5.80 | |$19.33 |$7.73 |

|Employee + Spouse |$29.01 |$11.61 | |$38.68 |$15.47 |

|Employee + Child |$29.01 |$11.61 | |$38.68 |$15.47 |

|Employee + Family |$43.51 |$17.40 | |$58.01 |$23.21 |

9 month premiums are taken over the 9 month academic year. 9 month premiums are calculated by taking the 12 month premium, multiplying by 24 paychecks and dividing by 18 paychecks.

Vision Premiums Per Paycheck

| |Premiums for 12 month |Premiums for 9 month employees |

| |employees | |

| |Pay Period Contribution |Pay Period Contribution |

|Employee Only |$2.81 |$3.75 |

|Employee + Spouse |$5.93 |$7.91 |

|Employee + Child |$6.34 |$8.45 |

|Employee + Family |$10.13 |$13.51 |

9 month premiums are taken over the 9 month academic year. 9 month premiums are calculated by taking the 12 month premium, multiplying by 24 paychecks and dividing by 18 paychecks.

Group Life & AD&D [pic]

Cost is 25¢ per $1000 of coverage (multiplied by the employee’s percentage rate*)

Maximum benefit $75,000

12 month Calculation: Annual Salary x 2, rounded up to nearest $1000 = benefit amount / 1000 x .25 = monthly premium / 2 = per paycheck amount

Example: $30,000 x 2 = $60,000 / 1000 = $60 x .25 = $15.00 / 2 = $7.50 per paycheck*

9 month Calculation: Annual Salary x 2, rounded to nearest $1000 = benefit amount / 1000 x .25 = monthly premium x 12 / 18 = per paycheck amount

Example: $30,000 x 2 = $60,000 / 1000 = $60 x .25 = $15.00 x 12 = $180 / 18 = $10.00 per paycheck*

* NMSU pays a portion of this premium, base on your salary—see salary table above.

Long Term Disability[pic]

Cost is 14¢ per $100 of covered basic monthly salary (multiplied by the employee’s percentage rate*)

Maximum benefit $5,000 per month

12 month Calculation: Monthly Salary / 100 x .14 = monthly premium / 2 = per paycheck amount

Example: $1000.00 / 100 = $10 x .14 = $1.40 / 2 = $ .70 cents per paycheck*

9 month Calculation: Monthly Salary / 100 x .14 = monthly premium x 12 / 18 = per paycheck amount

Example: $1000.00 / 100 = $10 x .14 = $1.40 x 12 = $16.80 / 18 = $.93 cents per paycheck*

* NMSU pays a portion of this premium, based on your salary—see salary table above.

Voluntary Life [pic]

Employee cost is 100% of premium

Cost is based on age; refer to plan brochure at

12 month Calculation: Amount Elected / 1000 x age based rate* = monthly premium / 2 = per paycheck amount

Example: $50,000 / 1000 = $50 x .06* = $3 / 2 = $1.50 per paycheck

9 month Calculation: Amount Elected / 1000 x age based rate* = monthly premium x 12 / 18 = per paycheck amount

Example: $50,000 / 1000 = $50 x .06* = $3 x 12 = $36 / 18 = $2.00 per paycheck

Benefit Enrollment/Change Form

Instructions

Incomplete forms will be sent back to the employee for completion. Forms must be re-submitted to the Benefit Services department within the 31 days deadline from the date of regular, benefit eligible employment or the date of the qualifying event for changes. Forms not received within the deadline or missing supporting documentation will not be processed.

1. EMPLOYEE INFORMATION

► Complete the information requested

► New Hire – Complete if you are enrolling in benefits within the first 31 days of benefit eligible employment.

► Date of Qualifying Event/Change in Status – The date the event occurred (i.e. date of marriage, divorce, etc).

► Reason for Change – Completed when making changes to benefit coverage due to a qualifying event. Documentation supporting the requested change must be attached. A list of acceptable documents is available on the Benefit Services website at .

2. DEPENDENT INFORMATION

► Complete the information on all dependents you wish to add or drop from coverage

▪ DP Child--Designate children of domestic partner by checking the DP Child box

▪ Social Security number--if dependent has not been issued a social security card, indicate in the social security box and contact the Benefit Services department with the number once the card has been issued

► If you plan to cover a domestic partner, please read NMSU policy regarding domestic partner benefits and complete the required paperwork to establish a qualified domestic partner relationship with NMSU.

► Employees adding coverage for dependents will need to provide documentation supporting the relationship and eligibility of the dependent, including spouses and domestic partners, with the enrollment form. A list of acceptable documents is available on the Benefit Services website at .

3. PRE-TAX PREMIUM

► Read the Pre-tax Premium statement on the enrollment form and complete as requested.

SECTIONS 4-9 MARK THE APPLICABLE BOX

► Decline Coverage –within first 31 days of employment and do not want this coverage

▪ Group Life & AD&D, Long Term Disability and Voluntary Life & AD&D—read statement of understanding and initial

► New Enrollment –not currently enrolled in the benefit and electing to enroll within 31 days of benefit eligible employment or within 31 days of a qualifying event

► Late Enrollment –missed the initial eligibility deadline and electing to add the benefit.

▪ Information regarding late enrollment restrictions and effective dates is available at .

▪ Late enrollment is not available for Dental.

▪ Late enrollment for Group Life & AD&D, Long Term Disability and Voluntary Life & AD&D is contingent upon approval from Dearborn National. Submit an Evidence of Insurability Form directly to Dearborn National.

► Change to Existing Enrollment –making a change to a benefit you are currently enrolled in due to a qualifying event or keeping your coverage and cancelling coverage for one or more dependents. See Reason for Change above.

► Cancellation –cancelling existing coverage for you and all dependents (if applicable).

▪ Vision, Medical, and Dental--Cancellation can only occur for a qualifying event. Cancellation without a qualifying event will be available each spring during the annual enrollment period with an end coverage date of June 30th.

▪ Group Life & AD&D, Long Term Disability and Voluntary Life & AD&D—once coverage is cancelled, re-enrollment is only available through late enrollment or qualifying event.

► No Change –no changes to this benefit.

4. VISION PLAN

► Employee- yourself (the employee) only

► Employee/Spouse or Employee/Domestic Partner –yourself (the employee) and a legal spouse or domestic partner.

► Employee/Child (ren)– yourself (the employee) and a child or multiple children but will not cover a spouse or domestic partner

► Family–yourself (the employee), a spouse or domestic partner and a child or children

5. MEDICAL PLAN

► Employee –yourself (the employee) only

► Employee/Spouse or Employee/Domestic Partner–yourself (the employee) and a legal spouse or domestic partner

► Employee/Child –yourself (the employee) and one child only. If more than one child will be covered, mark Family

► Family–yourself (the employee) and at least two family members.

► Medical Plan Options – designate the medical plan you plan to participate in under the coverage option you choose. Refer to Benefit Plan Summaries for each carrier for more details on plan coverage.

6. DENTAL PLAN

► Employee –yourself (the employee) only

► Employee/Spouse or Employee/Domestic Partner –yourself (the employee) and a legal spouse or domestic partner.

► Employee/Child –yourself (the employee) and one child only. If more than one child will be covered, mark Family

► Family–yourself (the employee) and at least two other family members.

7. GROUP LIFE & AD&D INSURANCE

► I Elect Coverage –read the statement of understanding to the right and initial on the line provided.

8. LONG TERM DISABILITY

► I Elect Coverage –read the authorization statement to the right and initial on the line provided.

9. VOLUNTARY LIFE & ACCIDENTAL DEATH & DISMEMBERMENT(AD&D) INSURANCE

► I Elect Coverage –The employee must elect coverage in order to cover family members.

▪ Indicate the amount of coverage you wish to purchase for both Voluntary Life and AD&D to the right. See plan details for coverage limits and enrollment requirements.

10. PRIMARY BENEFICIARY DESIGNATION

► Complete if you elected Group Life & AD&D, and/or Voluntary Life & AD&D or would like change beneficiary designation

► If additional space is needed, provide additional beneficiary information on separate page and note “see attached” on form.

► Keep a copy of your life enrollment section and your beneficiary designation sections with your personal records.

11. CONTINGENT BENEFICIARIES

► Complete to designate contingent beneficiaries for Group Life & AD&D, and/or Voluntary Life & AD&D.

► Contingent beneficiaries receive benefit if the primary beneficiary predeceases you.

► If additional space is needed, provide additional beneficiary information on separate page and note “see attached” on form.

12. EMPLOYEE AUTHORIZATION AND SIGNATURE

► Sign and date the enrollment form

► If you elected Group Life & AD&D, and/or Voluntary Life & AD&D, and listed someone other than your spouse as your primary beneficiary, your spouse should sign and date the form.

-----------------------

Benefit Services

New Mexico State University

MSC 3HRS, Box 30001

Las Cruces, NM 88003-8001

Phone: (575) 646-8000

Fax: (575) 646-2806

benefits@nmsu.edu

[pic]

AD&D Premiums

Per Paycheck

12 month 9 month

Employee Contributions Employee Contributions

|Coverage Amount|Individual |Family | |Coverage Amount |Individual |Family |

| |Coverage |Coverage | | |Coverage |Coverage |

|$20,000 |.21 |.32 | |$20,000 |.28 |.43 |

|$30,000 |.32 |.48 | |$30,000 |.43 |.64 |

|$40,000 |.42 |.64 | |$40,000 |.56 |.85 |

|$50,000 |.53 |.80 | |$50,000 |.71 |$1.07 |

|$60,000 |.63 |.96 | |$60,000 |.84 |$1.28 |

|$70,000 |.74 |$1.12 | |$70,000 |.98 |$1.49 |

|$80,000 |.84 |$1.28 | |$80,000 |$1.12 |$1.71 |

|$90,000 |.95 |$1.44 | |$90,000 |$1.27 |$1.92 |

|$100,000 |$1.05 |$1.60 | |$100,000 |$1.40 |$2.13 |

|$110,000 |$1.16 |$1.76 | |$110,000 |$1.54 |$2.35 |

|$120,000 |$1.26 |$1.92 | |$120,000 |$1.68 |$2.56 |

|$130,000 |$1.37 |$1.92 | |$130,000 |$1.82 |$2.56 |

|$140,000 |$1.47 |$2.24 | |$140,000 |$1.96 |$2.99 |

|$150,000 |$1.58 |$2.40 | |$150,000 |$2.10 |$3.20 |

|$200,000 |$2.10 |$3.20 | |$200,000 |$2.80 |$4.27 |

|$250,000 |$2.63 |$4.00 | |$250,000 |$3.50 |$5.33 |

Benefit Services

New Mexico State University

MSC 3HRS, Box 30001

Las Cruces, NM 88003-8001

Phone: (575) 646-8000

Fax: (575) 646-2806

benefits@nmsu.edu

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