STATE OF TENNESSEE GROUP INSURANCE PROGRAM …STATE OF TENNESSEE GROUP INSURANCE PROGRAM ENROLLMENT CHANGE APPLICATION State of Tennessee • Department of Finance and Administration

PART 3: HEALTH COVERAGE SELECTIONSELECT AN OPTION EMPLOYEE HSA SELECT A CARRIER REGION WHERE SELECT A HEALTH PREMIUM LEVEL

q Premier PPO q CDHP/HSA (state)

q Standard PPO

LOCAL ED & GOV ONLY MAY ALSO CHOOSE

q Limited PPO

q Local CDHP/HSA

CONTRIBUTION (STATE ONLY)

Annual contribution

$

q BlueCross BlueShield Network S

q Cigna LocalPlus

q Cigna Open Access (surcharge applies)

YOU LIVE OR WORK

q East

q Middle

q West

q employee only

q employee + child(ren)

q employee + spouse

q employee + spouse + child(ren)

PART 4: DENTAL COVERAGE SELECTION PART 5: VISION COVERAGE SELECTION PART 6: DISABILITY SELECTION (ST/UT/TBR)SELECT A PLAN SELECT A DENTAL PREMIUM LEVEL SELECT A PLAN

q Basic Plan

q Expanded Plan

SELECT A VISION PREMIUM LEVEL

q employee only


q employee + spouse


SHORT TERM DISABILITY

q 14/14 Elimination Period

q 30/30

Elimination Period

LONG TERM DISABILITY (ST ONLY)

q 60%/90 day Elim Period




q MetLife DPPO

q Cigna Prepaid DHMO

q employee only


q employee + spouse


Active employees should return this completed form to your agency benefits coordinator. COBRA participants should send to Benefits Administration.

PART 7: DEPENDENT INFORMATION — ATTACH A SEPARATE SHEET IF NECESSARYNAME (FIRST, MI, LAST) DATE OF BIRTH RELATIONSHIP GENDER ACQUIRE DATE * SOCIAL SECURITY NUMBER HEALTH DENTAL VISION

q M q F q q q

q M q F q q q

q M q F q q q

* The acquire date is the date of marriage, birth, adoption or guardianship.Proof of a dependent’s eligibility must be submitted with this application for all new dependents (see page 2). q A separate sheet with more dependents is attached

AGENCY SECTION — RETURN THIS FORM TO YOUR AGENCY BENEFITS COORDINATORORIGINAL HIRE DATE COVERAGE BEGIN/END DATE POSITION NUMBER EDISON ID NOTES TO BENEFITS ADMINISTRATION

AGENCY BENEFITS COORDINATOR SIGNATURE DATE

q PPACA Eligible q 1450 Eligible

FA-1043 (rev 08/17)

PART 1: ACTION REQUESTED — PLEASE SEE PAGE 4 FOR INSTRUCTIONSTYPE OF ACTION COVERAGE PARTICIPANTS REASON FOR THIS ACTION Life Event Special Enrollment

q Add coverage

q Change coverage

q Terminate coverage

q Health

q Dental

q Vision

q Disability

AFFECTED

q Employee

q Spouse

q Child(ren)

q New Hire/Newly Eligible

q Termination

q Court Order

q Other

q Marriage

q Newborn

q Legal Guardianship

q Adoption

(also complete pg 3)

q Death

q Divorce

q Loss of Eligibility

PART 2: EMPLOYEE INFORMATIONFIRST NAME MI LAST NAME DATE OF BIRTH GENDER

q M q F

MARITAL STATUS

q S q M q D q W

SOCIAL SECURITY NUMBER EMPLOYING AGENCY EMPLOYER GROUP: q UT q TBRq State q Local Ed q Local Gov

YOUR CURRENT STATUS

q Active q COBRA

HOME ADDRESS q UPDATE MY ADDRESS CITY ST ZIP CODE COUNTY

PART 8: EMPLOYEE AUTHORIZATION

q Accept I confirm that all of the information above is true. I know that I can lose my insurance if I give false information. I may also face disciplinary and legal charges. I understand that if my dependent loses eligibility, coverage will terminate at the end of the month in which the loss of eligibility occurs. I further understand that it is my responsibility to notify my benefits coordinator of the loss of eligibility and I will be held responsible for any claims paid in error for any reason. I authorize my employer to take deductions from my paycheck to pay for my benefit costs. Finally, I authorize healthcare providers to give my insurance carrier the medical and insurance records for me and my dependents.

q Refuse I have been given the opportunity by my employer to apply for the group insurance program and have decided not to take advantage of this offer. I understand that if I later wish to apply, I or my dependents will have to provide proof of a special qualifying event or wait until annual enrollment.

EMPLOYEE SIGNATURE DATE HOME PHONE (REQUIRED) EMAIL ADDRESS (REQUIRED)

RDA SW20

STATE OF TENNESSEE GROUP INSURANCE PROGRAMENROLLMENT CHANGE APPLICATIONState of Tennessee • Department of Finance and Administration • Benefits Administration312 Rosa L. Parks Avenue, 19th Floor • Nashville, TN 37243 • 800.253.9981 • fax 615.741.8196

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Counties and Regions For Health Plans

West East

Active employees can select the region where they either live or work. COBRA participants must select the region where they live.

Out of state residents: If you do not live in Tennessee, you will be eligible to enroll in the middle region options.

- 4 -

INSTRUCTIONSPlease complete the entire form and do not leave anything blank. Leaving a section blank can cause a delay in processing your request.

To add, change or terminate health, dental or vision coverage during the annual enrollment period, follow these instructions for each section in Part 1:

TYPE OF ACTION — mark the box indicating that you want to add, change or terminate coverage

COVERAGE AFFECTED — mark all that apply

PARTICIPANTS AFFECTED — mark all that apply

REASON FOR THIS ACTION — indicate reason for action – if making changes during annual enrollment period mark “Other” and write in AEP

Please make sure the rest of the form is filled out completely and be sure to sign and date the form. If you are an active employee, return your completed form to your agency benefits coordinator.

Middle

FA-1043 (rev 08/17) RDA SW20

Designation of Beneficiary for Unpaid Compensation

Upon the death of a University of Memphis employee who was in active pay status at the time of death, the University of Memphis will pay unpaid compensation, which may include annual leave, sick leave, and/or earnings, due at the time of death. This form may be used to designate such a beneficiary. If you do not designate a beneficiary, all money becomes payable to the estate of the deceased employee.

Employee Information:

_________________________________________________________ _______________________________ Employee Name Social Security Number

Beneficiary Designation: In the event of my death while actively employed by the University of Memphis, please pay to the following person or institution any unpaid compensation due at the time of my death.

Primary Beneficiary:

_________________________________________________________________________________________________ Last Name First Name MI Birth date Sex Relationship

_________________________________________________________________________________________________ Address including street, city, state, and zip code

_________________________________________________________________________________________________ Telephone Number

Secondary Beneficiary: Should the primary beneficiary shown above be deceased at the time of my death, please pay any unpaid compensation to the following person:

_________________________________________________________________________________________________ Last Name First Name MI Birth date Sex Relationship

_________________________________________________________________________________________________ Address including street, city, state, and zip code

_________________________________________________________________________________________________ Telephone Number

I hereby revoke any previous beneficiary designations for unpaid compensation:

_________________________________________________________________________________________________ Employee Signature Date

A Tennessee Board of Regents Institution An Equal Opportunity/Affirmative Action University

State of Tennessee, County of________________________________

______________________________________________ personally appeared before me on this _________ day of _________________, 20____, who makes oath that he or she executed this instrument.

______________________________ My commission expires:__________________ Notary Public (Notary Seal)

State of TN Retirement Plan Election Form

A Tennessee Board of Regents Institution An Equal Opportunity/Affirmative Action University

Section I: Employee Information

Employee Name__________________________________________ UID______________________________________ Hire Date________________ Title of Position____________________________ Work Phone_____________________ Section II: Retirement Plan Election ____ I hereby elect to participate in the Tennessee Consolidated Retirement System (TCRS), and thereby, waive my right, at this time, to participate in the Optional Retirement Plan (ORP). OR ____ I hereby elect to participate in the State of TN Optional Retirement Plan (ORP), and thereby, waive my right to participate in the Tennessee Consolidated Retirement System (TCRS). Complete Section III to designate ORP vendor(s). This election is made with the understanding that I must participate in either TCRS or the ORP under the following conditions:

1. I cannot participate in both plans at the same time. 2. Election to participate in the ORP is irrevocable as long as employment is continuous. If transferred to another

state institution where the ORP is available, I must continue to participate in the ORP. 3. Under current law, a member of TCRS who is eligible to participate in the ORP may elect to transfer prospective

membership to the ORP upon complying with specified filing requirements. Employee contributions may be transferred, but employer funds will not be transferred.

Section III: ORP Vendor Selection (skip if electing TCRS) If electing to participate in the ORP, you must specify distribution of your ORP contributions among the three ORP vendors. You must specify a percentage (no fractions) to each company in such a way that the sum equals 100%. Each percentage must be a whole number. Remember: You must complete an online enrollment for each vendor selected.

Total distribution to VOYA:

Total distribution to TIAA-CREF:

Total distribution to VALIC:

Section IV: Employee Signature I have read the foregoing instrument and have elected to join either the ORP or TCRS and execute a waiver of all prospective benefits in the plan for which I have elected not to join. Further, I understand (per TBR Policy 5:01:03:03) that failure to elect either plan within 31 days of my eligibility date will initiate my enrollment by default into the TCRS. Employee Signature_______________________________________________ Date______________________________ Section V: Human Resources Retirement Code(s) ______________ Payroll effective date__________________

______________

Code Description R50 ORP VOYA R60 ORP TIAA-CREF R70 ORP VALIC R56/R66 Hybrid TCRS D80 401(k) D81 Roth 401(k)

Participation Agreement for Section 403(b) Tax-Deferred Annuity

Employee: ____________________________________ Social Security Number: ____________________________________ By this agreement made between The University of Memphis (employer) and the employee named above, the parties hereto agree as follows: Employee does hereby request and employer does hereby agree to reduce by the amount(s) indicated below and to pay such amount(s) to the company(s) as indicated below for the purpose of purchasing for the employee an annuity qualifying under the terms of Section 403(b) of the Internal Revenue Code. Effective Payroll Date: ________________ Termination Date: ________________ or Continue until canceled.

Company Name Co. Code Amount Per Payroll

Annual Amount Old Amount New Amount

$ $ $

$ $ $

$ $ $

Total $ $ $

Effective Payroll Date: ________________ Termination Date: ________________ or Continue until canceled.

Company Name Co. Code Amount Per Payroll

Annual Amount Old Amount New Amount

$ $ $

$ $ $

$ $ $

Total $ $ $

This agreement shall be legally binding and irrevocable as to each of the parties hereto while employment continues; provided, however, that either party may terminate this agreement as of the end of any pay period, so that it will not apply to salary subsequently earned, by giving written notice prior to the beginning of such pay period of the date of termination. Both parties hereby acknowledge that this agreement is intended to qualify amounts involved for salary deferral. It is the parties’ intent that the annuities purchased, the determination of limitations or exclusion allowance, and other matters directly related to the administration of the employer’s deferred compensation plan be consistent with sections 403(b) and 415 of the Internal Revenue Code and all related regulations, rulings, or other authoritative provisions, in addition to the employer’s administrative rules and procedures. Employer shall have the right to unilaterally terminate this agreement if employer has reason to believe continued salary reductions would cause excess contributions, per Internal Revenue Service provisions, to result from continuation. Employer shall have the right with or without seeking employee’s advice to direct any company named above to refund to employee any “excess” contributions as such defined by Internal Revenue Service. Execution of this agreement does hereby cancel any agreements for salary reduction previously executed by employee for the employer’s § 403(b) tax-deferred annuity plan. This agreement supersedes and replaces all such prior agreement. In consideration of execution by employer of this agreement, employee hereby agrees to indemnify and hold harmless and release employer and its trustees, officers, and employees from all claims and liability of any type directly or indirectly arising out of this agreement. Employee acknowledges awareness that participation in certain deferred compensation arrangements with another employer could result in disallowance of deferral of some or all of above amounts. Employee certifies that any and all prior years’ participation in a §457 plan has been disclosed in writing to employer, as well as any previous “election” under §415(c)(4). Employee’s Approval: Employer’s Approval: ________________________________________________ ________________________________________________ Signature Date Signature Date Memorandum Notations:

Other:

State of tenneSSee Group InSurance proGram

Basic life insurance Beneficiary designation applicationState of tennessee • Department of finance and administration • Benefits administration19th floor, 312 rosa L. parks avenue • nashville, tennessee 37243 • 615.741.3590 or 800.253.9981

eMployee inforMationname Social Security number edison ID (if known)

employing Department/agency Dept ID Date of Hire Date of Birth

Work address city State Zip code

Home address city State Zip code

marital Statusq Single q married q Divorced q Widowed

Genderq male q female

Daytime phone number

autHoriZationI understand that this enrollment is not for health insurance coverage and is for basic term life and basic accident coverage only. unless I enroll in family health insurance, coverage is provided to the employee only (not spouse or child). If I enroll in family health insurance coverage, my covered dependents will also be enrolled in basic life coverage; however dependents do not elect a beneficiary as the benefit will automatically default to me as the employee. I further understand that a new application must be completed and returned to my agency benefits coordinator any time I want to designate a new beneficiary. failure to designate a beneficiary will result in the proceeds being paid to my spouse, children, parents or estate according to applicable contract provisions in the event of my death.

I authorize the state group insurance program to release information to their life insurance contractor on behalf of myself and all family members (name, address, social security number, age, gender, salary, enrollment effective/termination date) required to establish eligibility and coverage levels for the purpose of obtaining life insurance coverage. this authorization shall be in force for the time period I have a pending application or am enrolled with this life insurance company. the state group insurance program will not condition treatment, payment or enrollment eligibility on the signature of this authorization and may not have the right to control further disclosures of this information.

upon termination of employment, I may convert my basic term life coverage to an individual policy with the insurance company. payment of monthly premiums directly to the insurance company will be my responsibility.

I confirm that all information that I have provided on this application is accurate. I understand that providing false and/or misleading information may subject me to disciplinary and/or legal action. I authorize my employer to deduct the required premium from my salary/wages.

employee Signature Date

type of reQuest

q new enrollment

q Beneficiary add/change

effective date of beneficiary designation:

enrolled in health coverage:

q Yes q no

If yes, type of health coverage:

q employee only

q employee + dependents

this application is to be used to designate a beneficiary for basic life insurance coverages. Individuals who elect not to enroll in health insurance will be provided with basic term life and basic accident coverage with the premium being provided by the State of tennessee. these amounts of coverage cannot be increased.

Individuals who do elect health coverage will also receive the same state support; however, the amount of coverage will increase as your salary increases, with additional premiums deducted from your paycheck. If enrolling in health coverage, covered dependents will also receive life insurance benefits; however, the amount of coverage is different from that of an employee.

please refer to the eligibility and enrollment guide for further information.

fa-1005 (rev 10/13)

complete beneficiary designation on back of this application and return to your agency benefits coordinator

PRIMARY BENEFICIARY DESIGNATION

Name Social Security Number Relationship Percent of Benefi t

Home Address City State Zip Code









Total for Primary Benefi ciary (must be 100%) Total

CONTINGENT BENEFICIARY DESIGNATION











Total for Contingent Benefi ciary (must be 100%) Total

NOTE: Contingent benefi ciary will only receive benefi ts if all primary benefi ciaries are deceased.

Name Edison IDOR

SSN

State of tenneSSee Group InSurance proGram

Voluntary accidental death enrollment applicationState of tennessee • Department of finance and administration • Benefits administration312 rosa L. parks avenue, 19th floor • nashville, tn 37243 • 615.741.3590 or 800.253.9981 • fax 615.741.8196

authoriZation

I confirm that all the above information is accurate. I understand that providing false and/or misleading information may subject me to disciplinary and/or legal action. I authorize my employer to deduct the required premium from my salary/wages.

I authorize the state group insurance program to release information to their life insurance contractor on behalf of myself and all family members (name, address, social security number, age, gender, salary, enrollment effective/termination date) required to establish eligibility and coverage levels for the purpose of obtaining life insurance coverage. this authorization shall be in force for the time period I have a pending application or am enrolled with this life insurance company. the state group insurance program will not condition treatment, payment or enrollment eligibility on the signature of this authorization and may not have the right to control further disclosures of this information.

I understand that a new application must be completed and returned to my agency benefits coordinator any time I want to designate a new beneficiary. failure to designate a beneficiary will result in the proceeds being paid to my spouse, children, parents or estate according to applicable contract provisions in the event of my death. Dependents do not elect a beneficiary as the benefit will automatically default to me as the employee.

empLoyee SIGnature Date

type oF reQueSt action For enrollment change

q new enrollment

q employee only

q employee + dependents

q add Dependent

q terminate Dependent

q update Dependent eligibility

q terminate coverage

q add/change Beneficiary

q change coverage type to: q Single q family

q enrollment change effective Date of change:

fa-0831 (rev 9/15)

employee inFormationfIrSt name mI LaSt name Date of BIrth GenDer

q m q f

marItaL StatuS

q S q m q D q W

SocIaL SecurIty numBer empLoyInG aGency DaytIme phone numBer eDISon ID

home aDDreSS cIty St ZIp coDe

dependent inFormation

name (fIrSt, mI, LaSt) Date of BIrth reLatIonShIp GenDer acquIre Date * SocIaL SecurIty numBer

q m q f

q m q f

q m q f

q m q f

* the acquire date is the date of marriage, birth, adoption or guardianship. proof of a dependent’s eligibility must be submitted with this application for all new dependents.

complete beneficiary designation on back of this application and return to your agency benefits coordinator

rDa SW20

primary BeneFiciary deSignationname phone numBer SocIaL SecurIty numBer reLatIonShIp percent of BenefIt

home aDDreSS cIty State ZIp coDe

name phone numBer SocIaL SecurIty numBer reLatIonShIp percent of BenefIt








total For primary BeneFiciary (muSt Be 100%) total

note: contingent beneficiary will only receive benefits if all primary beneficiaries are deceased.

name eDISon IDor

SSn

contingent BeneFiciary deSignationname phone numBer SocIaL SecurIty numBer reLatIonShIp percent of BenefIt










total For contingent BeneFiciary (muSt Be 100%) total

Optional Group Term Life Insurance Enrollment

Minnesota Life Insurance Company - A Securian Company Group Administration Department 400 Robert Street North St. Paul, Minnesota 55101-2098

A A abcd

EMPLOYER NAME: State of Tennessee POLICY NUMBER: 34175

Reason for Enrollment: Family Status Change Date of Family Status ChangeNew Hire Annual Enrollment

1. Complete sections A, B, and F. 2. If you are electing coverage on your dependents, complete sections C, D, and/or E.

If you have questions, please contact Minnesota Life at 1-866-881-0631.

A. EMPLOYEE INFORMATION

First name Middle initial Last name

Email address

Street address City State Zip code

Date of birth Social Security number Date of employment Gender

FemaleMale

Total amount of insurance requested ($5,000 increments to a maximum of 7 times base annual salary or $500,000, whichever is less. Up to 5times base annual salary is guaranteed if elected within 30 days of hire. Electing 6x or 7x base salary will require you to complete the separate Evidence of Insurability form.)

Check this box for the $5,000 Annual Enrollment increase ONLY$

B. EMPLOYEE BENEFICIARY INFORMATION

Primary beneficiary(ies) designation (include full name and address)The person or persons named will receive the benefits.

Share % (Primarybeneficiaries must total 100%)

Relationship

RelationshipContingent beneficiary(ies) designation (include full name and address)If the primary beneficiary(ies) is no longer living, the benefit is paid to this person(s).

Share % (Contingentbeneficiaries must total 100%)

PLEASE NOTE: If you do not designate a beneficiary, any death proceeds would be paid out at State of TN's plan default: 1. Spouse 2. Child(ren) 3. Parent(s) 4. Estate of Insured

C. SPOUSE INFORMATION

First name Middle initial Last name

Email address

Has your spouse been hospitalized, advised to seek medical treatment, or received disability benefits in the past six months? Yes No

Date of birth Social Security number Gender

FemaleMale

Total amount of Spouse Optional Term Life insurance requested

$20,000 (Spouse under age 55 only) $10,000 $15,000$5,000$25,000 (Spouse under age 55 only) $30,000 (Spouse under age 55 only)

D. SPOUSE BENEFICIARY DESIGNATION (if no beneficiary is designated, employee will be the default beneficiary for spouse coverage)

RelationshipPrimary beneficiary(ies) designation (include full name and address)The person or persons named will receive the benefits.

Share % (Primarybeneficiaries must total 100%)

Contingent beneficiary(ies) designation (include full name and address)If the primary beneficiary(ies) is no longer living, the benefit is paid to this person(s).

Share % (Contingentbeneficiaries must total 100%)

Relationship

03-30566.41 EdF77977 Rev 9-2013

E. CHILDREN INFORMATION (Employee is the beneficiary of child coverage)

List of names and dates of birth for your eligible children:

Total amount of insurance requested

$10,000$5,000

F. AUTHORIZATION

I authorize my employer to withdraw premiums from my salary to pay for supplemental insurance coverage.

I authorize the State Group Insurance Plan to release to Minnesota Life on behalf of myself and all family membersinformation (name, address, Social Security number, age, gender, salary, enrollment effective/termination dates) requiredto establish eligibility and coverage levels for the purpose of obtaining life insurance coverage. This authorization shall bein force for the time period I have a pending application or am enrolled with this life insurance company. The State GroupInsurance Plan will not condition treatment, payment, or enrollment eligibility on the signature of this authorization andmay not have the right to control further disclosures of this information.

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposeof defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Employee signature Daytime telephone number Evening telephone number Date signed

X

03-30566.41 EdF77977 Rev 9-2013

GLAD 4 01/12 (TN)

The Lincoln National Life Insurance Company P.O. Box 2616, Omaha, NE 68103-2616

Phone: (800) 423-2765 Fax: (877) 573-6177

ENROLLMENT FORM FOR GROUP INSURANCE

Please Use Ink or Type

GROUP ID: TENNBOR

GROUP POLICY #: 1023334000000

Billing Division or Location:

A. Employee Information (Complete for ALL Enrollments) Employer Name/Company Name (Please Print)

County Employer ZIP State

Employee Last Name First Name Middle Initial

Social Security Number Date of Birth

Street Address City State Zip

Gender: Male Female Marital Status: Married Single Home Phone ( )

Work Phone ( )

Completed By Employer Average Hours Worked Per Week: Occupation:

Earnings: Hourly Monthly Weekly Yearly

$

Date of Full-Time Employment:

Rehire Date:

Voluntary Coverage NOTE: Please mark the box or boxes for each coverage you are applying for. All coverage amounts are subject to the limitations and exclusions as stated in the policy.

TYPE OF COVERAGE AMOUNT OF COVERAGE TOTAL PREMIUM

Voluntary Long Term Disability Yes No* Level 1 Plan – 50% to $2,000 max Level 2 Plan – 60% to $4,000 max Level 3 Plan – 60% to $7,000 max

$

*By selecting No, application for coverage at a later date may require further medical information and/or a physical exam, which will be at my own expense.

--Actual deductions may vary slightly from above illustrations due to rounding--

E. Request for Coverages

This coverage has been offered to me and after careful consideration of the benefits, I have decided to:

REQUEST COVERAGE for which I am or may become eligible under the group policies issued by The Lincoln National Life Insurance Company. I hereby enroll for group insurance, for which I am eligible or may become eligible. If contributions are required, I authorize my employer to deduct premiums from my salary.

NOT ENROLL myself in the Program. I understand that if I enroll for coverage at a later date, and if a physical examination or further medical information is required, it will be at my own expense.

NOTE: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN

INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES INCLUDE

IMPRISONMENT, FINES, AND DENIAL OF INSURANCE BENEFITS.

The insurance requested on this enrollment form will not be effective until approved by the Group Insurance Service Office of The Lincoln National Life Insurance Company, or its insurance partners, and the initial premium is paid to The Lincoln National Life Insurance Company. A delayed effective date will apply if the employee is not Actively at Work or an Active Member, or a dependent is in a period of limited activity on the date insurance would otherwise take effect. Employee Full Name: Employee Signature: Date:

Health/Limited/Dependent Care Flexible Spending Account (FSA)

Enrollment Form I. Personal Information (Please print clearly and provide complete and accurate information.)

Your Employer: _______________________________________ Employer ID# _______________________

Member # ______________________ Your Name _________________________________________________________ (This may be your SSN or employer assigned number) (Last) (First) (MI)

Address ___________________________________City ________________________ State ______ Zip _________-_______

Check if this address is new within last year. Date of Birth ______ / ______ / ______ Hire Date ______ / ______ / ______

II. Election Information (Please check the appropriate box to indicate if you wish to enroll, or do not wish to enroll, and sign below.)Yes, I wish to participate in the Limited Purpose and/or Dependent Care FSA plan and authorize payroll reduction from my salary on a pre-tax basis in theamount(s) indicated below, and continuing until this election is amended or terminated or until the Plan Year ends. Employer-sponsored benefit coveragecontributions are automatically reduced from my compensation on a pre-tax basis.

Yes, I wish to participate in the Heath Care and/or Dependent Care FSA plan and authorize payroll reduction from my salary on a pre-tax basis in theamount(s) indicated below, and continuing until this election is amended or terminated or until the Plan Year ends. Employer-sponsored benefit coveragecontributions are automatically reduced from my compensation on a pre-tax basis.

I have been offered the opportunity to enroll in the flexible spending account plan and do not wish to enroll at this time. However, my employer-sponsoredbenefit coverage contributions are automatically reduced from my compensation on a pre-tax basis.

BENEFIT CHOICES PER PAY PERIOD AMOUNT

NUMBER OF PAY PERIODS

PLAN YEAR AMOUNT

Health Care Flexible Spending Account (FSA) If you are enrolled in a Health Savings Account, you cannot enroll

in a Health Care FSA. $________.____ X ________ = $__________.___

Limited Purpose Flexible Spending Account Only available if you are enrolled in a Health Saving Account. $________.____ X ________ = $__________.___Dependent Day Care Flexible Spending Account If married, this amount is less than my spouse’s earned income.

Please refer to the IRS guidelines for further information. $________.____ X ________ = $__________.___

I understand that:

If enrolled in an HSA, I may only participate in a Limited Purpose FSA.

This election can only be changed or revoked during the Plan Year if I have a change in status as defined in the Plan or if I am no longer eligible to

participate. The new election must be consistent with my change in status, must be applied for within 30 days of the change, and is subject to final approval

by my employer.

This election will be automatically changed or cancelled, if necessary, to comply with provisions of the Internal Revenue Code or if required employer-

sponsored benefit contributions increase or decrease.

The maximum exclusion under a Dependent Care Reimbursement Account for married individuals filing a joint return is $5,000 per calendar year. Married

individuals filing separately will get a lower exclusion ($2,500 per calendar year). IRS Form 2441 must be filed with my personal income tax return.

Any amounts remaining in my reimbursement accounts at the end of the Plan Year will be forfeited.

Salary contributed into one reimbursement account cannot be transferred and used for expenses in any other account.

A new Enrollment Form must be completed each Plan Year. If I do not complete and return an Enrollment Form during Open Enrollment, I forfeit the

opportunity to participate in the Benefit Choices outlined above.

Social Security and Medicare taxes are not being withheld on the amount of my salary reduction under this election.

The amount of salary reductions may not be claimed on my or my spouse’s income tax returns.

If my employment terminates, only medical expenses incurred through my period of coverage as defined in the Plan can be considered for reimbursement.

I understand all claims submitted for reimbursement are subject to substantiation requirements and I am required to, and agree to, provide documentation as

requested.

If using the PayFlex Debit Card, I agree to use the card for eligible expenses only and retain all itemized receipts/statements. I agree to read and adhere to

the cardholder statement I receive with the card and I understand the card is subject to inactivation if I do not comply with the provisions or upon termination

of employment.

Any expenses I pay for with the PayFlex Debit Card or for which I claim reimbursement will not have been nor will I seek to have reimbursed elsewhere.

III. Pre-Authorization for Direct Deposit (If you are already enrolled in direct deposit or do not wish to, ignore this section.)

I authorize PayFlex Systems USA, Inc. to initiate a credit and/or debit entry to my account for my PayFlex reimbursements.

This agreement is to remain in full effect until written notification is supplied by me to PayFlex terminating this agreement.

A “VOIDED” CHECK MUST ACCOMPANY DIRECT DEPOSIT APPLICATION

Employee Signature ____________________________________ Date _________________ Rev.11/2014

EMPLOYER MUST FILL-IN

Re-enrollment __ New __ Change __

Effective Date _________________

1st Deduction Date _____________

Payroll Mode W B S M Q

Division Code _________________

Employee Authorization for Payroll Deduction to Health Savings Account

Return this form to AD 165. Keep a copy for your records.

You must be enrolled in a consumer-driven health plan (CDHP) with a HSA before you can start a payroll deduction.

I wish to:

Begin a deduction Change my deduction Stop my deduction Effective date______________

Your payroll office can confirm the effective date.

Section 1: Employee Information

Name___________________________________________ (Last, First, Middle initial)

Mailing address___________________________________

City/State/ZIP_____________________________________

SSN or employee ID _______________

Work phone number________________

Agency name_____________________

Section 2: Calculate Your Maximum HSA Contribution Use the worksheet below to determine how much you can contribute to your HSA in 2018.

Select your enrollment status

Individual HSA Family HSA

A. Maximum amount that can be put in your HSA for 2018 $3,450 $6,900

B. Are you age 55 or older? No, write $0. Yes, write $1,000

C. How much your employer will contribute in 2018D. A + B – C =The most you can contribute in 2018If your contributions exceed the amount in D, you risk paying IRS tax penalties. If you are submitting a midyear change, be sure to include any amounts you have already contributed in 2018.

Section 3: Calculate Your Per-Paycheck HSA Contribution Continue the worksheet to determine how much you will contribute to your HSA per paycheck.

Individual HSA Family HSA

Total from D. $__________ Total from D. $___________

E. Number of paychecks you will receive in 2018__________

E. Number of paychecks you will receive in 2018________

F. D ÷ E =This is the most you can contribute per paycheck$__________

F. D ÷ E =This is the most you can contribute per paycheck $_______

Amount you elect to contribute to your HSA per paycheck Can be any amount up to or less than F $__________

Amount you elect to contribute to your HSA per paycheck Can be any amount up to or less than F $___________

Employee’s Signature Required

By signing this form, I am requesting that payroll deductions be started or changed as shown in Section 3 above and agree to the preceding terms. I understand there are maximum limits I can contribute to my HSA per IRS rules and I may be liable for tax penalties if I exceed this amount. This request replaces any previous payroll deduction requests for my HSA.

Employee’s signature Date

Benefits Office Use

Employee’s annual contribution Number of paychecks remaining for 2018

Employee’s contribution per paycheck

$ $

Documents

STATE OF TENNESSEE GROUP INSURANCE PROGRAM …STATE OF TENNESSEE GROUP INSURANCE PROGRAM ENROLLMENT CHANGE APPLICATION State of Tennessee • Department of Finance and Administration