Hewitt, Coleman Associates, Inc



2017 Hourly ASSOCIATES Benefits Enrollment/CHANGE Form

Employee Information

|Name:_____________________________________________________ |SS# ___ ___ ___ - ___ ___ - ___ ___ ___ ___ |

|Street: _____________________________________________ |City: ______________ |State: _____ |Zip:________ |

|Gender: ( Female ( Male |Marital Status: ( Single ( Married ( Divorced ( Separated |

|Date of Birth: _______________ |Date of Hire: _______________ |Check one: ( Hourly ( Salary |

Medical Premium Incentive

A premium incentive towards the cost of your medical insurance is offered for non-tobacco users. If you are currently a tobacco user but wish to quit and be eligible for the Non-Tobacco User rate, Metromont offers a free Tobacco Cessation Program. Eligibility to receive the Non-Tobacco User premium incentive is contingent upon: 1) signing the Non-Tobacco User Affidavit and being certified as a non-tobacco user, or 2) participating in the Tobacco Cessation Program. Please refer to the Tobacco Cessation Program Overview for full details.

If you choose to participate in the Vitality Program, you will a premium incentive once you achieve Platinum status. Until that time, you will pay either the Tobacco or Non-Tobacco User rate for your respective plan election.

2017 Associate Contribution Rates

|Tier Level |Basic Plan (per pay) |Plus Plan (per pay) |Vitality Platinum Status |

| | | |(per pay) |

| |Tobacco User |Non-Tobacco User |Tobacco User |Non-Tobacco User |

|( |( |( |( |( |

Do you, your spouse, or children have other medical insurance coverage? Yes ( No ( If YES, please provide names of those covered, the carrier name, and policy number:___________________________________________________________________________________________

|Dental Plan |Per Pay |

|Employee Only |$4.87 |

|Employee + 1 |$9.20 |

|Employee + 2 or more |$17.85 |

Dental (check one):

|Employee Only | Employee + 1 |Employee + 2 or more |No Coverage |

|( |( |( |( |

|Vision Plan |Per Pay |

|Employee Only |$1.97 |

|Employee + 1 |$3.83 |

|Employee + 2 or more |$5.62 |

Vision (check one):

|Employee Only | Employee + 1 |Employee + 2 or more |No Coverage |

|( |( |( |( |

Health Savings Account (HSA) Election

Please indicate the amount you wish to contribute to your 2017 Health Savings Account via payroll deduction or write $0 for no contribution. The maximum annual HSA contribution amount for 2017 is $3,400 for employee-only and $6,750 for family coverage (including any employer contribution amount). An additional $1,000 catch-up contribution is allowed for participants age 55 and older.

HSA Election $____________________ (per pay)

Dependent Care Flexible Spending Account

Please indicate the amount you wish to contribute to your 2017 Dependent Care Flexible Spending Account or write $0 for no contribution. The maximum annual Dependent Care FSA contribution amount for 2017 is $5,000.

Dependent Care FSA Election $____________________ (per pay)

Dependent Information

Please complete the section below for any eligible dependent you wish to enroll or remove from coverage. Eligible dependents include your legal spouse and your child(ren) up to age 26. Disabled dependent children of any age are eligible for coverage as long as they are enrolled at the time their coverage would otherwise have ended. Certification of disability for coverage beyond age 26 may be required.

|Name |

|(First & Last) |

Effective Date: _______________________________________ Location: ___________________________________________________________

Completed By: ________________________________________

2017 Non-Tobacco User Affidavit

INSTRUCTIONS: Please select ONE of the options listed below to designate your tobacco user status.

OPTION 1

In order to qualify for the Non-Tobacco User premium incentive towards the cost of your medical insurance for the 2017 benefit plan year, you must sign the affidavit below.

I hereby certify that I have not smoked, chewed, dipped, or otherwise used any form of tobacco product in the last 120 days. I understand that I will lose my eligibility for the non-tobacco user premium incentive toward the cost of my medical insurance if this certification and the information provided on this form are not true and accurate. I also understand that I will be subject to disciplinary action for providing falsified documents if the information is found to be untrue. Lastly, I agree to be subject to random cotinine/nicotine testing at any time during the benefit plan year.

Associate Signature: _________________________________ Date: ___________________

Associate Printed Name: _____________________________ Employee ID #: ___________

OPTION 2

If you are tobacco user but wish to quit, you may still qualify for the premium incentive towards the cost of your medical insurance by participating in the Tobacco Cessation Program. You must enroll in the Tobacco Cessation Program within 30 days from the start date of your medical insurance coverage and agree to comply with all program requirements, including being subject to a cotinine/nicotine test upon completion of the program.

Within 30 days from the start date of my medical insurance coverage, I agree to enroll in the Tobacco Cessation Program and that effective immediately, I will be eligible to receive the premium incentive towards the cost of my medical insurance while participating in and complying with program requirements.

I understand that I will lose my eligibility for the non-tobacco user premium incentive if 1) I fail to enroll in the Tobacco Cessation Program within the allotted timeframe, and/or 2) this certification and the information provided on this form are not true and accurate. I also understand that I will be subject to disciplinary action for providing falsified documents if the information is found to be untrue. Lastly, I agree to be subject to random cotinine/nicotine testing at any time during the benefit plan year.

I understand that if I do not comply with program requirements or drop out of the program prior to the scheduled program end, I will no longer be eligible for the premium incentive towards the cost of my medical insurance and not be allowed to re-enroll in the program for a period of sixty (60) days.

Associate Signature: _________________________________ Date: ___________________

Associate Printed Name: _____________________________ Employee ID #: ___________

OPTION 3

I am a tobacco user and do not wish to participate in the Tobacco Cessation Program. As a result, I understand that I am not eligible to receive the premium incentive towards the cost of my medical insurance and will be charged the tobacco user rate. However, I may elect to have my tobacco user status re-classified as a non-tobacco user in the event I elect to participate in the Tobacco Cessation Program at a later date.

Associate Signature: _________________________________ Date: ___________________

Associate Printed Name: _____________________________ Employee ID #: ___________

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