2012 International Change Form.doc



2015 INTL Life Event Change Form Instructions

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Please check the appropriate boxes on the enrollment form to indicate your benefit selections for 2015.

Medical Insurance – Medical coverage is provided by CIGNA Global and is available for you and your eligible dependents.

Dental Insurance – Dental coverage is also provided by CIGNA Global and is available for you and your eligible dependents. The premium for Employee only coverage is 100% paid by CARE.

Supplemental Vision and Supplemental Vision Plus – Supplemental Vision is available ONLY inside of the United States. Supplemental Vision Plus offers an out-of-network benefit (including international claims). See “Frequently Asked Questions” for more details. NOTE: Vision care and eyeglasses ARE NOT covered under the medical plan. Services rendered outside the US are reimbursable ONLY under the Supplemental Vision Plus.

**Supplemental Life Insurance – CARE automatically provides basic life insurance equal to two times your gross annual salary. You may elect

an additional (“supplemental”) life insurance in an amount equal to one to four times your gross annual wage. You are responsible for paying for the cost of this additional life insurance coverage. Your total amount of life insurance (basic + supplemental) cannot exceed $750,000.

If you choose to increase your supplemental life insurance coverage amount at annual enrollment by more than one times your annual gross salary or $50,000 whichever is less AND your supplemental coverage amount equals $150,000 or more, you will be required to submit an Evidence of Insurability. Once your enrollment form has been received and the Compensation and Benefits Unit has determined you require Evidence of Insurability, the form will be forwarded to you. If you have any questions contact the HR Services Center at HRServiceCenter@.

To calculate your monthly cost: 1) Determine total amount of supplemental coverage (gross salary x number of times electing, 1-4), 2) Divide by

$1000, 3) Multiply that amount by the rate for your age range on the below chart. If needed, see “Frequently Asked Questions” for an example.

| Age |

|Social Security No.* |Date of Birth (MM/DD/YYYY) |Male |Single |Employee ID Number |

| | |Female |Married | |

|Street Address |

|City |State |Zip Code |

*If you do not have a Social Security Number, please indicate “not applicable:.

□ Add a dependent(s)

□ Delete a dependent(s)

□ Drop coverage List Coverage(s)_________________________________________________________

Please check the reason for the change in coverage and the effective date of the change.

□ Marriage on ________________________________

□ Divorce on _________________________________

□ Birth or adoption of a child on ___________________________

□ Death of a dependent on ________________________

□ Termination or commencement of spouse’s/domestic partner’s employment on ______________________

□ Change in your or your spouse’s employment status (part-time to full-time or vise versa) on _________________

□ Other (please explain) ________________________________________________________________________________

I elect to make the following changes to my coverage. I understand that these changes must be requested within thirty-one (31) days of the qualifying event and that proof of the change will be requested.

Please check the appropriate boxes below to reflect your new benefit selections:

Medical Dental Vision OR Vision Plus

Employee Only ( $46.24/mo ( $0 – CARE paid ( $1.23/mo ( $ 4.80/mo

Employee+One ( $108.34/mo ( $13.11/mo ( $2.28/mo ( $9.03/mo

Employee+Family ( $145.80/mo ( $34.11/mo ( $3.32/mo ( $13.23/mo

Drop Coverage ( Waive ( Waive ( Waive ( Waive

( No Change ( No Change ( No Change ( No Change

If you do not elect any coverage option, you will default to the “WAIVED” category.

If you waive medical or dental benefits above, you must complete page 2 of this enrollment form.

Supplemental Life* Dependent Life Supplemental Long-Term Disability**

(1X (2X (3X (4X ( Add CARE pays 100% ( Yes $__________

( Waive ( Waive ( Waive

AD & D (Spouse) AD & D (Child)

See “Instructions” page See “Instructions” page

( CARE paid ( CARE paid

( Waive ( Waive

Dependent Information

If you are adding or dropping a dependent(s), please list below:

Last Name |

First Name |

M.I. |Coverage

M = Medical

D = Dental

V = Vision |Date of Birth

MM/DD/YYYY |Gender

M = Male

F = Female |Relationship*** |At Post

Y = Yes

N = No |At Post

Y = Yes

N = No | | | | | | | | | | | | | | | | | | | | | |*** Please indicate “SP” for Spouse, “C” for Child, “DC” for Disabled Child and “DP” for Domestic Partner. “Child” refers to unmarried dependent children up to age 26. “Disabled Child” refers to a child of any age who is disabled according to SSA guidelines.

Signature and Authorization

I confirm that I have made the above benefit selections consistent with my change in job/family status. I understand that these changes must be requested within thirty-one (31) days of the qualifying event. I hereby authorize the deduction from my earnings of any required contributions toward the cost of such insurance. I also authorize the release of the respective insurance company or its representatives any medical information or insurance information deemed necessary to process a benefits claim on my dependents or me. I authorize any educational institution to furnish my employer or insurance carrier with information necessary to establish student eligibility. I certify that the information provided on this form is accurate and complete.

Employee’s Signature (do not print) Date

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