Human Resources Weinstein Hall, First Floor

231 Richmond Way

Benefit Enrollment/Change Form University of Richmond, VA 23173 (804) 289‐8747 Fax: (804) 287‐1282

urhr@richmond.edu hr.richmond.edu

Last Name: __________________________ First Name:___________________________ Middle Initial: _______ UR ID#: ________________ Effective Date: ____________ (requires approval by HR) Paid: Monthly Bi‐weekly

Form Submission Reason New Hire* Marital Change Birth/Adoption Ineligible Dependent

Employment/Benefit Change Beneficiary Change Other‐ Please Explain:______________________ Date of Event/ Hire Date:

________________ It is the responsibility of the employee to complete an enrollment application for one of the University's health insurance plans or waive coverage, as well as all other

benefits, no later than 31 calendar days after his or her employment start date. If an employee fails to comply with this requirement, the University will understand this to mean the employee is declining health insurance coverage, as well as all other benefits, and may not enroll until Open Enrollment unless there is an eligible status change.

Qualifying EventEmployees have 31 days from the qualifying event date to add or remove themselves, a dependent, or spouse from coverage. Supporting or additional

documentation may be required. Qualifying status change reasons and dependent eligibility details are located at https://hr.richmond.edu/benefits/insurance/medical-plans/pdf/welfare-plan-document.pdf#page=8

Medical Plan: Cigna Waive Coverage: Proof of other coverage required

5 days’ vacation - Pro-rated $500 - Pro-rated (faculty must select this option)

Enroll Decline

Coverage Level Employee Only Employee plus Child Employee plus Spouse Employee plus Family

Vision Plan: UniView Vision Enroll Decline

Coverage Level Employee Only Employee plus Child Employee plus Spouse Employee plus Children Employee plus Family

Dependent InformationDependent Children may remain on health/dental/vision until Dec. 31 of the year they turn 26. Please list additional dependents on page 2 and submit all required documentation as listed on page 3 within 31 days of hiring or qualifying life event.Add/ Remove

Name: Last, First, M.I. SSN Relation Legally Married (Y/N)

DOB Gender(M/F)

Medical Hospital Accident

Self

Spouse

Child

Child

Child

Child

Child

Employee plus Family w/ Spousal Surcharge

Dental Plan: Anthem

Employee Only Employee plus Child Employee plus Children

Employee plus Family Employee plus Spouse Employee plus Spouse w/ Spousal Surcharge

Dental Vision

Traditional High Deductible Deductible Health Plan (HDHP) - $1,750

High Deductible Deductible Health Plan (HDHP) - $4,000

Health Savings Account‐ Only eligible when enrolled in HDHP plan, cannot be on another health plan, Medicare or have a FSA. Must completeenrollment online at https://hr.richmond.edu/benefits/common/hsa-enrollment-form.pdf

Enroll - Must complete enrollment form above Amount per pay period:_______________ Decline1

Flexible Spending‐ You may not elect this if enrolled in the HDHP. Flexible Spending Accounts must be re‐elected every year or your FSA account willbe termed December 31st. Complete enrollment form and submit to HR ‐ http://hr.richmond.edu/forms/fsa‐enrollment‐form.pdfMedical Flexible Spending‐ ($2,700 household maximum)

Enroll Annual amount: _____________ Decline Dependent Care Flexible Spending‐ ($5,000 household maximum)

Enroll Annual amount: _____________ Decline

Voluntary Life Insurance‐ Complete enrollment form and submit to HR http://hr.richmond.edu/benefits/common/insurance-application.pdfApplicant Decline Enroll‐ Requested

Amount Guaranteed Coverage Amount (only available during new hire enrollment. Requests above these amounts requires Life Insurance application)

Max Coverage‐ requires health statement to be completed

Employee Number of $10,000 units _____

$10,000 units ______

The lesser of 2 X’s your salary or $200,000 The lesser of 5 X’s your salary or $500,000

Spouse‐ up to age 70

Number of $10,000 units ______

$30,000 $50,000

Child(ren)‐ 14 days to age 23

Number of $2,000 units ______

$10,000

Legal Resources‐ (NEW HIRES ONLY) Enroll at www.legalresources.com/enroll_now Company ID: 264 Password: nhlegal Decline

Beneficiary DesignationBasic Life Insurance – Policy No. FLX960295 (If needed, list additional beneficiaries on attached page) Employee’s Primary Beneficiary(ies):

Relationship to Employee Social Security Number Date of Birth % (total must equal 100)

Employee’s Contingent Beneficiary(ies):

Relationship to Employee Social Security Number Date of Birth % (total must equal 100)

Voluntary Term Life Insurance– Policy No. FLX960295 (If needed, list additional beneficiaries on attached page) Employee’s Primary Beneficiary(ies):

Relationship to Employee Social Security Number Date of Birth % (total must equal 100)

Employee’s Contingent Beneficiary(ies):

Relationship to Employee Social Security Number Date of Birth % (total must equal 100)

Guidelines for Designation of Beneficiaries Primary and Contingent Beneficiaries‐ Unless you designate a percentage, proceeds are paid to the primary surviving beneficiaries in equal shares. Proceeds are paid to contingent beneficiaries only when there are no surviving primary beneficiaries. If you designate contingent beneficiaries and do not designate percentages, proceeds are paid to the surviving contingent beneficiaries in equal shares. Unless otherwise provided, the share of a beneficiary who dies before the insured will be divided proportionately among the surviving beneficiaries in the respective category (primary or contingent). General‐ Please be sure to include the beneficiary’s full name, social security number and relationship to you. Providing this information can help expedite the claim process by making it easier to locate and verify beneficiaries. Trust as Beneficiary‐ You may designate a trust as a beneficiary, using the following form: “To [name of trustee], trustee of the [name of trust], under trust agreement dates [date of trust].” If you wish to designate a testamentary trust as a beneficiary (i.e., one created by will), you should recognize the possibility that your will which was intended to create this trust may not be admitted to probate (because it is lost, contested, or superseded by a later will). Claim payment delays can result if the beneficiary designation doesn’t provide for this situation.

By completing this form you attest that your covered dependents are eligible dependents under the University of Richmond Employee Welfare Benefits Plan, or that you do not wish to cover dependents under the plan at this time. You understand that the University may require you to provide documentation to prove your dependents are indeed eligible for benefits, and you agree to provide such documentation upon request. You understand that your provision of dependent information is the basis on which dependent coverage will be provided under the plan. You acknowledge that you will notify the plan administrator of any changes to your dependent information within 31 days of the change. Any misstatement, omission or fraud by you may result in future claims being denied, your coverage and/or your dependents’ coverage being prospectively terminated without notice and/or retroactively terminated upon 31 days’ notice, and/or your submission to disciplinary action. You, and any person authorized to act on your behalf, are entitled to receive a copy of this form upon the appropriate request.

______________________________________________________Employee Signature

_______________ Date

Voluntary Accident InsuranceApplicant Enroll

Employee

Employee/Child(ren)

Decline

Employee/spouse

Employee/Family

Voluntary Hospital InsuranceApplicant Enroll Decline

Employee

Employee/Child(ren)

Employee/spouse

Employee/Family

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If you are adding a dependent to a medical, vision, or dental insurance plan because you are a new employee or have experienced a qualifying life event, documentation proving eligibility is required. Enrollment in the insurance plans will not be processed without required documentation.

Please note that international documents without an official English translation will not be accepted. Documents must be provided no later than 31 days after hiring or after the qualifying life event occurs.

The following is acceptable documentation for dependent verification.

Relationship Eligibility Requirements Documentation to Submit

Legal Spouse • Legal spouse of the Employee The following document: • Employee's 2018 or 2019 filed federal

income tax return Form 1040 – the firstpage only (social security numbers andfinancial information should be blackedout).

Children UNDER age 26

• Biological child(ren);• Stepchild(ren);• Legally adopted child(ren) or

child(ren) placed in your home forfinal adoption;

• Foster child(ren);• Child(ren) under legal

guardianship;• Child(ren) covered under a

Qualified Medical Child SupportOrder.

ONE of the following documents: • Birth certificate listing parents or adoption

paperwork; issued by a State or County;or

• Employee's 2018 or 2019 filed federalincome tax return Form 1040 – the firstpage only listing the dependent children(social security numbers and financialinformation should be blacked out); or

• Qualified Medical Child Support Order(QMCSO) which requires child supportfor benefit coverage; or

• Court paperwork for legal guardianship.

Disabled Children OVER age 26

• An unmarried child who becamedisabled before reaching age 26and is incapable of self-sustainingemployment by reason of mentalor physical handicap.

BOTH of the following documents: • The required documentation for a child

UNDER age 26 listed above; AND• Any documentation verifying a

permanent disability that began beforethe child attained age 26.

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Required Documents for Dependent Verification

Complete this form annually if you are enrolling your spouse in the University of Richmond's medical plan. If you are NOT enrolling your spouse in the University's medical plan this form is not needed. If your spouse is covered on the University's plan and you fail to complete this form or are late turning it in, you will be responsible for a surcharge in the amount of $100 per month. More information about the surcharge is on page 5.

URID# _____________ Employee Name _____________________________________

Spouse Name _________________________________________________

Form due date: Form is due within 30 days of hiring or qualifying life event.

CERTIFICATION

I do hereby attest that the above information is true and correct to the best of my knowledge. I acknowledge that falsification of any information may lead to disciplinary action, up to and including employment termination. I understand UR reserves the right to request supporting documentation and any proof as it, in its sole discretion, deems necessary in order to verify the representations I have made in this Affirmation. I also understand that if my spouse’s group medical insurance status changes, it is my responsibility to notify Human Resources within 30 days of such change. I further understand a spouse surcharge may be terminated at the first of the month following timely notification to Human Resources. Spouse surcharge refunds for late notification are not permitted.

Employee Signature ___________________________________________ Date _______________

University of RichmondAnnual Affirmation of Spousal Medical Insurance Coverage

I am enrolling my spouse in the University of Richmond's health insurance plan and understand I should not need to pay the surcharge:

My spouse is employed/retired, but is not eligible for or not offered health insurance through their employer or retirement plan. (For a full list of exceptions, visit: https://hr.richmond.edu/benefits/open-enrollment/rate-sheet.html#surcharge.) Spouse’s Employer or Retirement Plan Name and Human Resources Phone #: _________________________________________________________________________My spouse is unemployed or retired and not covered under any other employer‐sponsored health coverage.My spouse is also a full-time University of Richmond employee, but I elect to cover them on my plan.

I am enrolling my spouse in the University of Richmond's health insurance plan and understand I will need to pay the surcharge:

My spouse has coverage available through an employer or retirement plan, but I elect coverage on the University of Richmond's health insurance plan. I understand that I will be charged a $100 per month surcharge as a result.

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Information about the Health Insurance Spousal Surcharge

UR imposes a $100 per month surcharge on employees that elect to cover spouses who are eligible for group medical coverage through their own employer, spouses that are retired and have access to a health plan through their previous employer or retirement plan, or spouses of participants on the COBRA plan. If, at any point, your spouse ceases to be eligible for their medical coverage, they may be enrolled in your UR medical plan. You will have 30 days from the loss of eligibility to enroll your spouse in UR's plan.

The surcharge will be treated as an additional premium and will be a pre-tax deduction. Monthly employees who are assessed the surcharge will have a $100 deduction each paycheck and hourly employees will have a $50 deduction each pay period (24 paychecks).

If your spouse's open enrollment occurred earlier in the year and your spouse chose not to enroll in coverage for which they were eligible for, they should contact their employer and request to enroll in their employer’s benefit plan. An open enrollment under your spouse's employer’s benefit plan is considered a mid‐year change in status.This surcharge does not apply toward dependent children. You are still able to enroll your dependent children in the UR medical plan regardless of your spouse’s status under this restriction.

This surcharge does not apply to a spouse when both parties are employed at UR and covered under a UR plan.

If you do not return this Affirmation to Human Resources, and you are enrolling a spouse in a UR medical plan, you will be charged the $100 spousal surcharge until you submit this form. Spousal surcharge refunds for late notification are not permitted. You may not make any changes to your election until the following annual benefit enrollment period unless you experience a qualifying event.

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