State qf Nevada SEE BACK SIDE FOR INSTRUCTIONS Benefits Em-ol[Iment I Committee On Benefits Please Print and Change Form Action Itequired Address: Effective Date of Change: - New Hire: Name:H Date of Ma@iage: -Retiree: Beneficiary: @ Date of Birth/Adoption: - Su@iving Spous )endent: Open Enrollment: n Change Plan, moved from se@ice area: From: - to: I - Cob@C Add/Delete Dependent: n Reason: - E NAm@E LAST FiHsr mi SOCIAL SECITRIW NU BIRTH I)ATE SEX m F [] IIENLALF@[:] MALF, p 0MAILIN(; ADDRESS HOME PIIONE OTIIERINSURANCE COVE@"El L R 0 YES 0 m ONO y ANEW N@E WORKPHONE FUI,L TIMP, 80, E T 0 YES rl No E INEW MAILINC@ ADDRESS IIIRE DATE I'AYCENTFR 0@@'I'REET A@. ('ITY STATE zli@ N State Self-Funded Health Plan @ Basi(: p6tl stato stfi-r-@ @itaith Ple.Ti-Aften,,.,)tive Plan Health Plan Choices FHP (HMO) - South - Primary Care Physician Health Plan of Nevada (HMO) - South - Primary Care Physician I Choose: Hospital Health Plan (HMO) - North - Primary Care Physician I Decline/Waive Coverage for Myself - Reason: I Choose coverage for: Employee Oilly 0 Employee+Spouse @ Employee+Child/Children [] Employee+Family Family Information - Use additional page if needed, be sure to sign and date. Please list all eligible family members to be enrol,ed, changed, or deleted. A copy of your marriage certificate and a copy of your child/children's birth certificate(s) are required when electing depenct6nt coverage. ACTION NAME @FX RELATIONSHIP I BIRTH DATE SSN STUDRNT OTFIER INS, STATIJ,@ COVERAC@P. AI)II 13 NIA @s El Cl@G@@ [3 SPOUSE NO DFI-F@TF C) AI)D 13 YF"s ri yi"@, c@@GE 13 NO n NO n F)ELETE [3 ADD 13 YES Y ES '@HAN@F@ a NO NO DELETE [3 ADII 13 YES YFS icl@NGE 0 NO NO ,EI,ETE n I JADD 131 YES c@G@@ 0 NO DELETE Q Provide the following information for any eligible family members covered by other health insurance. OTHER INSURANCE N"E ADDRESS IDNUMBER EMPLOYER F- L Life Insurance Beneficiary Designation NAME MAILING ADDRESS RE@TIONSHIP(S) PERCENTAGE(S) PRIMARY SE(@ONDARY Employee Certification I certify that the above answers are true to the best of my knowledge and that I have read and understand Risk Management Use the authorization on the back of this form. I am aware if I elect not to enroll myself or my eligible dependents, Coverage satisfactory evidence of ggod health for myself/dependents will be required before coverage can be effective. Effective Date: I hereby authorize my employer to deduct any required contributions from my earnings for the coverage I Evidence of Insurability have selected. POP: El Yes 0 No Signature Date: Date/Initials Return Completed Fo= To: Risk Management, 209 E. Musser, Room 104, Carson City, NV 89710 EMPLOYEE Instructions for Completing the State of r4evada Benefits Enrolbnent and Change Form lxnportant: Read "Benefit Directions" before enrolling for coverage. Make an informed choice! Action Required 1. Indicate whether you are a new hiretretiree enrolling for the first time, or 2. Changing your name or address, or adding or deleting dependents, or changing your beneficiary(ies) by checking the appropriate box. 3. Be sure to indicate the Effective Date of Change and the Date of Marriage and/or Birtli/Adoption, if appropriate. 4. If you are changing medical plans because you have moved from the service area of your previous plan, indicate the plan you are moving from and going to (e.g., From: State Self-Funded Plan, To: HHP). Employee Information 6. Complete all requested information, 7. If your name or address has changed, be sure to include your new name/address. Health Plan Choices 8. Choose the one health plan in which you want to participate. If you choose one of the HMOS, be sure to indicate a Primary Care Physician. You also can choose to decline/waive coverage for yourself. 9. You may elect coverage for yourself and your eligible dependents, indicate your coverage election. F@ @ormtion 10. Indicate the activity, name, birth date and Social Security number for your eligible family members to be covered. Indicate whether the dependents a@ full-time students. 11. Indicate whether eligible family members are covered under any other health insurance plan. Benefic@ Desigmtion 12. Indicate the name, address and relationship of your primary beneficiary, and secondary if you wish, for your life insurance coverage. A secondary beneficiary is paid if the primary dies before you do. 13. If you designate more than one primary or secondary beneficiary, indicate the percentage of benefits you wish distributed to each. Percentages must @l 100%. Employee CerMcation 14. Be sure to sign and date the form. If an additional page is used to provide information, be sure it is signed and dated, keep a copy for yourself and attach the.original copy to your Enrollment/Change form. By signing, I acknowledge that I have read and understand the authorization shown below. I understand I am applying to the State for coverage for myself and my dependents, if any, as shown on this form. Ifaccepted as a group member, my employer is authorized to deduct the appropriate amount and remit to the carrier selected. I understand that any mis@tements on this form may be used as a basis for recision of insurance for me and my dependents (if any) from the original effective date. I @er understand that if the insurance applied for becomes effective, I will be subject to all the terms of the group pohey(ies). I authorize any licensed physician, medical practitioner, hospital, clinic or other medical related facility, insurance company, or other organization, employers, or other person that has any information available as to my health or that of any member of my family covered under this plan to give the carrier I have chosen or its legal representative any such information. A photographic copy of this authorization shall be as valid as the oti&al. Please keep your copy of the Benefits Enrollment ForiW