EdCare Group Health Plan Enrollment Form

Revised August 2015

EDCARE GROUP

GROUP HEALTH PLAN ENROLLMENT FORM

EMPLOYEE ENROLLMENT

Ο Male

_________________________________________ ____________________________________ _____ _____________________________ Ο Female Last Name First Name MI Social Security Number

______________________________________________________________________________ ___________________________________________

Complete Address – (Street # & Name, City, State, Zip Code) Date of Birth

Date of Hire____________________ Effective Date (leave blank) _____________________ Phone Number _________________________

FOR EMPLOYER USE ONLY: Ο Kingsburg Elementary Ο Fowler Unified Ο State Center CC

Ο New Hire Ο Change only If a change, prior coverage was through ________________ Date of Employment _____________________ Coverage Effective Date _________________

BENEFIT ELECTION Ο I elect the following coverage: Ο I decline coverage for:

Ο Modern Medical Plan Ο Spouse

Ο Bronze Medical Plan Ο Children

Ο Vision Plan (through Vision Service Plan) Ο Spouse and Children

Ο Dental Plan (through Ameritas) Reason: _____________________________________

DEPENDENT ENROLLMENT (Complete for each eligible dependent)

SPOUSE’S EMPLOYER: _______________________________________________________________________________________

Relationship First and Last Name SSN Date of

Birth

Does dependent have other

group coverage?

Husband

Wife

No

Yes

Carrier

Son

Daughter

Step-child

No

Yes

Carrier

Son

Daughter

Step-child

No

Yes

Carrier

Son

Daughter

Step-child

No

Yes

Carrier

Son

Daughter

Step-child

No

Yes

Carrier

Son

Daughter

Step-child

No

Yes

Carrier

EMPLOYEE SIGNATURE AND CONSENT I authorize all health care providers, claim processing agents, insurance and reinsurance agencies or other persons or organizations performing

direct administrative, professional, medical, or legal services in connection with my claims or care to disclose any information necessary for

investigation, evaluation, or payment of a claim. I certify that all information contained herein is true and correct.

__________________________________________________________________________ ________________________

Employee Signature Date

California Region Group Enrollment/Change Form Please print or type in black ink only. See instructions on reverse before completing this form. Make a copy for your records.

TO BE COMPLETED BY EMPLOYER

Company name Hire date (mm/dd/yyyy)

Group number Enrollment unitEffective enrollment/ change date (mm/dd/yyyy)

A. ENROLLMENT/CHANGE REASON (see Change Table for assistance) New group: ❑ Yes ❑ No

❑ New Hire (complete sections A, B, C, D) ❑ Open Enrollment (complete sections A, B, C, D) Health Plan (Check one) ❑ HMO Plan ❑ Deductible Plan ❑ Other

❑ Loss of Other Coverage (complete sections A, B, C, D) ❑ Other (please specify)

❑ Name Change (complete sections A, B, C, D) From: To:

Event Date (mm/dd/yyyy)

B. EMPLOYEE Have you ever been a Kaiser Permanente member? ❑ Yes ❑ No

Medical Record No. (if known) Social Security No.

Name (Last, First, MI) Birth Date (mm/dd/yyyy) Gender ❑ M ❑ F

Home Address City State ZIP

Work Phone Home Phone Email

Ethnicity Preferred Language

C. FAMILY For additional dependents, attach a separate sheet with employee’s name at top. (Last, First, MI)

❑ Add ❑ Delete ❑ Spouse ❑ Domestic partner Gender ❑ M ❑ F Social Security No.Spouse/domestic partner name: Birth Date (mm/dd/yyyy)Former last name (if any): Medical Record No.❑ Add ❑ Delete ❑ Child ❑ Student Gender ❑ M ❑ F Social Security No.Dependent name: Birth Date (mm/dd/yyyy)Relationship: Medical Record No.❑ Add ❑ Delete ❑ Child ❑ Student Gender ❑ M ❑ F Social Security No.Dependent name: Birth Date (mm/dd/yyyy)Relationship: Medical Record No.❑ Add ❑ Delete ❑ Child ❑ Student Gender ❑ M ❑ F Social Security No.Dependent name: Birth Date (mm/dd/yyyy)Relationship: Medical Record No.Do any of dependents above live at another address? ❑ Yes ❑ No If yes, complete the following:Name (Last, First, MI): Address:

D. Kaiser Foundation Health Plan, Inc., and Kaiser Permanente Insurance Company Arbitration Agreement*I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure, and, if I am enrolled in coverage that is subject to the ERISA claims procedure regulation, or any claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), Kaiser Permanente Insurance Company (KPIC),* any contracted health care providers, administrators, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in KFHP or coverage by KPIC, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Evidence of Coverage and in the Certificate of Insurance.

* Disputes arising from any of the following KPIC products are not subject to binding arbitration: 1) Tiers 2 & 3 of the Point-of-Service (POS) Plan; 2), the Preferred Provider Organization (PPO) and Out-of-Area Indemnity (OOA) Plans; and 3), the KPIC Dental Plans.

Signature Required for all Kaiser Permanente Plans Date(Excluding KPIC PPO, KPIC OOA, and KPIC Dental Plans)

88350Revision date 09/2013

General instructions

1. Please print firmly and legibly in black ink.

2. To enroll, the subscriber must reside or work within one of the ZIP codes listed on the enclosed sheet.

3. The employer must complete the first section titled “To be completed by employer.”

4. The employer is responsible for confirming all information prior to submitting, especially effective dates, as these affect your Health Plan dues.

5. The employee/subscriber must complete Sections A and B. See right column for detailed instructions.

6. Be sure to sign and date the bottom of the form.

7. Once the form is complete (including employer section), the subscriber should make a copy for his or her records, and to use as a temporary ID card, after the effective date.

8. All changes to accounts, including effective dates and child or student status, will be made in accordance with the contractual agreement between the purchaser and Kaiser Permanente.

Instructions for completing employer and new enrollment sections and sections A through D:To be completed by employer: The employer must complete all fields to ensure we have correct account and enrollment information.

Section A: The subscriber must complete this section.

Section B: The subscriber must always complete this section. Use the Change Table (below) for assistance.

Section C: The subscriber must indicate the requested change to the account and complete all fields for any dependents being enrolled. We will verify the eligibility of these dependents during the enrollment process. Be sure to include any former last names for both spouses and dependents. Also indicate the appropriate role. The student role should be marked only if the dependent qualifies as an “overage dependent” attending school. Please contact your employer regarding rules for overage dependent students. A completed Student Certification form may be required.

Section D: The subscriber must sign and date this section.

Change Table

Add dependent Event date

Acquired student status* Student status date

Family adoption* Adoption date

Loss of coverage Coverage loss date

New spouse (marriage) Marriage date

Moved into service area Move date

Newborn addition Birth date

Open enrollment Open enrollment effective date

Delete dependent Event date

Loss of student status Status change date

Divorce Divorce date

Member deceased* Death date

Delete dependent(s) Dependent termination date

Open enrollment Open enrollment effective date

Demographic Change Event date

Address change, telephone number change Status change date

Demographic (name, birthdate, social security number) change Status change date

*Additional documentation may be required.

California Region Group Enrollment/Change Form

88350Revision date 09/2013

48493-F Underwritten by ReliaStar Life Insurance Company DIS (03/10)

3BDisability Income Insurance Enrollment Form

INSTRUCTIONS: Top box to be completed by the Employer/Plan Sponsor. Remainder to be completed by the Employee.

Name of Employer/Plan Sponsor Alliance of Schools for Cooperative Insurance Programs

Group/Plan Number 67087-1

Account Number/Location 0021- State Center

0BClass/Occupation

1BDate of Hire (mm/dd/yyyy)

2BAnnual Salary

Employment Status:

Active Full-Time Active Part-Time

Retired

This change is due to: (check all that apply) Initial Eligibility Following Hire

Late Entrant* Other: ___________________________________________

Effective Date of Coverage or Change:

*A late entrant is an individual who is first enrolling for coverage after the first available opportunity. Employee Information Employee Name (last, first, middle initial)

Date of Birth (mm/dd/yyyy)

Social Security #

Employee I.D. #

Employee Address (street address, city, state, zip code)

Work Phone Number

Home Phone Number

Female Male

Disability Income Coverage When you are first eligible for disability income coverage, you can elect it without evidence of insurability. If you are a late entrant, you must complete an Evidence of Insurability form subject to approval by ReliaStar Life. Monthly Income Benefits (LTD)

Voluntary Benefits Elect Coverage (60% to $5,000 is available through payroll deduction) Waive

READ THIS INFORMATION CAREFULLY AND THEN SIGN AND DATE BELOW • I authorize my employer to deduct from my wages the premium, if any, for the elected coverage. • To the best of my knowledge and belief, the information I have provided on this form is correct. • I understand my coverage begins on the effective date assigned by ReliaStar Life, provided I am actively at work. • I also understand that evidence of insurability may be required for coverage to become effective. Any person who, knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and may subject such person to criminal and civil penalties, and denial of insurance benefits. Employee's Signature

Date Signed (mm/dd/yyyy)

48467 Underwritten by ReliaStar Life Insurance Company GATGI (03/10)

Life and AD&D Insurance Enrollment Form

INSTRUCTIONS: Top box to be completed by the Employer/Plan Sponsor. Remainder to be completed by the Employee. All new coverage or any increases in Life coverage will require evidence of insurability (proof of good health) if plan participation requirements are not met. Any references to coverage being obtained without evidence of insurability in the sections below are only applicable if the plan participation requirements are met.

Name of Employer/Plan Sponsor Alliance of Schools for Cooperative Insurance Programs

Group/Plan Number 67087-1

Account Number/Location 0021- State Center Community College District

Employee Information Employee Name (last, first, middle initial)

Date of Birth (mm/dd/yyyy)

Social Security #

Employee I.D. #

Employee Address (street address, city, state, zip code)

Work Phone Number

Home Phone Number

Female Male

Employee Life Insurance Basic Life Insurance Employee Only—Elect Coverage (Note: Basic Life insurance is employer provided.)

Beneficiary Information Designate your beneficiary(ies) below. Name of Beneficiary (last name, first, middle initial) Primary Relationship to Employee Benefit %

Address Date of Birth Social Security Number Phone Number

Name of Beneficiary (last name, first, middle initial) Primary Contingent Relationship to Employee Benefit %

Address Date of Birth Social Security Number Phone Number

Name of Beneficiary (last name, first, middle initial) Primary Contingent Relationship to Employee Benefit %

Address Date of Birth Social Security Number Phone Number

READ THIS INFORMATION CAREFULLY AND THEN SIGN AND DATE BELOW • I authorize my employer to deduct from my wages the premium, if any, for the elected coverage. • To the best of my knowledge and belief, the information I have provided on this form is correct. • I understand my coverage begins on the effective date assigned by ReliaStar Life, provided I am actively at work. • I also understand that evidence of insurability may be required for coverage to become effective. Employee's Signature

Date Signed (mm/dd/yyyy)

Employer: Plan Year: / / through / /

Employee Name: SSN:

Employee Address:

Email: Phone #: ( )

S125 BENEFIT SUMMARY

Status# of Ded

Effective Date Benefit/Company Section 125After-Tax Payroll Deduct

Employer Paid

Major Medical/

Dental Insurance/

Health Flexible Spending Account/AFA

Dependent Day Care Flexible Spending Account/AFA

Monthly Flex Admin Fee/AFA

Monthly Flex Card Fee/AFA

Cancer Insurance/

Life Insurance/

Disability Insurance/

Accident Insurance/

Health Savings Account(HSA)/

Other:

Totals:

FLEXIBLE SPENDING ACCOUNT ENROLLMENT ACCOUNT TYPE ANNUAL ELECTION HEALTH FSA CARD (Check one below)

Health Flexible Spending $ New Participant / Replacement Card

Dependent Day Care Flexible Spending $ Existing Participant with Card

Limited Purpose Health Flexible Spending $ I do not want a Health FSA Card ELIGIBLE DEPENDENTS (Must be at least 18 years of age)

(Health FSA Card will be mailed to new dependents or dependents with a replacement card request listed. For existing dependents listed the Health FSA Card will be reloaded with your new election.)

Dependent Name 1: ___________________________________ Relationship: ____________ New / Replacement Card Request Existing

Dependent Name 2: ___________________________________ Relationship: ____________ New / Replacement Card Request Existing

Dependent Name 3: ___________________________________ Relationship: ____________ New / Replacement Card Request Existing

TERMS AND CONDITIONSI hereby authorize the above payroll reductions as my contribution to my Employer’s Section 125 Plan.

I understand that:Execution of this benefit election/salary reduction agreement does not automatically institute insurance coverage; in most instances an

application for insurance must be completed. Premiums charged for insurance coverage may be adjusted by the carrier issuing the contract and my “take-home” pay may be higher or lower depending on the selections made.

If I have elected the HSA benefit, I certify that I have met all the HSA eligibility requirements, which have been separately disclosed to me, and that I will notify the Employer immediately in writing if I cease to meet any of the conditions for HSA eligibility during any month of the plan year.

I have received a copy of the Rules of Participation and understand and agree to the terms and conditions of participation in the Section 125Plan, Health Flexible Spending Account(s) and/or Health FSA Card.

If I do not repay the Health FSA for an overpayment due to an ineligible expense or other reason, my employer may make a deduction from my wages to repay the overpayment.

If I have elected a Health FSA Card, I certify (1) the Health FSA Card will only be used to pay for the eligible medical expenses of myself, my spouse, and my dependents; (2) the Health FSA Card will not be used for expenses that have already been reimbursed; (3) I will not seek reimbursement under any other health plan for expense paid for with the Health FSA Card; and (4) I will acquire and keep sufficient documentation for expenses paid with the Health FSA Card.

This authorization replaces any previous authorization I have made. Waive Participation

Employee Signature: Date: SB-29984-0315