<table>
<colgroup>
<col style="width: 26%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 11%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td>Social Security Number</td>
<td colspan="4">Fermi ID</td>
<td colspan="4">Employee Last Name</td>
<td colspan="5">Employee First Name</td>
<td colspan="2">Middle Initial</td>
</tr>
<tr class="even">
<td colspan="5">Street Address</td>
<td colspan="4">City</td>
<td colspan="5">State, Zip</td>
<td colspan="2">Home Phone</td>
</tr>
<tr class="odd">
<td><p>Date of Birth</p>
<p>(mm/dd/yyyy)</p></td>
<td colspan="4"><p>Marital Status</p>
<p> Single</p>
<p> Married</p></td>
<td colspan="4"><p>Hire Date</p>
<p>(mm/dd/yyyy)</p></td>
<td colspan="5"><p>Pay Frequency</p>
<p> Weekly</p>
<p> Monthly</p></td>
<td colspan="2">Work Phone</td>
</tr>
<tr class="even">
<td colspan="16"><em>Retirement</em></td>
</tr>
<tr class="odd">
<td colspan="7"> Please pay out my vacation as a lump-sum</td>
<td colspan="9"> I plan to run-out my vacation</td>
</tr>
<tr class="even">
<td colspan="7">Last Day Worked</td>
<td colspan="9">Date of Retirement</td>
</tr>
<tr class="odd">
<td colspan="16"><em>Medical Coverage</em></td>
</tr>
<tr class="even">
<td colspan="2"> CIGNA Open Access Plus</td>
<td colspan="9"> Blue Cross HMO Illinois</td>
<td colspan="5"> Blue Cross Blue Advantage HMO</td>
</tr>
<tr class="odd">
<td colspan="16">Benefits Office Use</td>
</tr>
<tr class="even">
<td colspan="2"> FRU 65 FRO 65</td>
<td colspan="9"> 0200 0400</td>
<td colspan="5"> 0200 0400</td>
</tr>
<tr class="odd">
<td colspan="3"><p> Retiree (Option Code 1)</p>
<p> Family (Option Code 4)</p>
<p>Effective Date ________________</p></td>
<td colspan="9"><p> Retiree (Option Code 1)</p>
<p> Family (Option Code 4)</p>
<p>Effective Date ________________</p></td>
<td colspan="4"><p> Retiree (Option Code 1)</p>
<p> Family (Option Code 4)</p>
<p>Effective Date ____________</p></td>
</tr>
<tr class="even">
<td colspan="16"><p>Benefits Office Use</p>
<p>Billing Effective Date __________________ 100% EE Flat Amount $
____________</p></td>
</tr>
<tr class="odd">
<td colspan="16">Please provide information below for yourself and your
eligible dependents to be covered under the Fermilab Retiree Medical
Plan</td>
</tr>
<tr class="even">
<td colspan="4">Name, Last/First/Middle Initial</td>
<td colspan="2">Gender</td>
<td colspan="2"><p>Birth Date</p>
<p>(mm/dd/yyyy)</p></td>
<td colspan="5">Social Security Number</td>
<td colspan="2">Blue Cross HMO Primary Care Physician Name</td>
<td><p>Blue Cross HMO Group Number</p>
<p>2-4 digits</p></td>
</tr>
<tr class="odd">
<td colspan="4"><em>Self</em></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><p><em>Spouse</em></p>
<p><em>Please Note: If spouse has not been covered under the Fermilab
plan for 3 continuous years, please provide proof of other group medical
coverage that has been in place for 3 consecutive years immediately
preceding your retirement date. )</em></p></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><em>Child</em></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td><p> Defer Coverage</p>
<p> Retiree Family</p></td>
<td colspan="5"> I will be employed and have other group coverage</td>
<td colspan="4"> There is other group coverage through my spouse’s
employer</td>
<td colspan="6">Notification must be made to the Fermilab Benefit Office
within 30 days of the termination date of employment or coverage
(whichever is earlier) to request reinstatement. Failure to make proper
notification will result in denial of reinstatement. Documentation of
continuous coverage required for reinstatement.</td>
</tr>
<tr class="even">
<td> Decline Coverage</td>
<td colspan="15">I understand that I cannot elect coverage at a later
date.</td>
</tr>
</tbody>
</table>

I understand that premiums for my medical coverage will be automatically
deducted from my bank account, on the first business day of the month.
Completion of an authorization agreement is required. I understand that
my coverage will be terminated for non-payment of my premiums. I
understand that my coverage once terminated cannot be reinstated. FRA
reserves the right to amend, modify or terminate the plan at any time.

Signature
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Benefits Office Signature
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_