Spreadsheet: 004ca41d-7e6f-4e64-8590-4231a8476ac7
Sheet: Enrollment Worksheet

City of Merced
2014 Open Enrollment Election Worksheet
Effective Date: 01/01/2014
Employee Information - Complete in Full
Employee Name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  | SSN: |  |  |  |  |  |  | Birth Date: |  |  |  |  |  |  | Gender:
Employee Address (Address, City, State, [NAME]): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Home Phone: |  |  |  |  |  | Hire Date: |  |  |  |  | [NAME]:
Occupation/Title: |  |  |  |  |  |  |  |  |  |  |  |  |  | Department: |  |  |  |  |  |  |  |  |  |  | Unit: |  |  |  | Annual Salary:
Dependents Information
Dependent Name |  |  |  |  |  |  |  |  |  |  | Dependent SSN: |  |  |  | Coverage Election: |  |  |  |  |  |  |  |  | Relationship: |  |  |  |  |  | Birth Date:
AUTHORIZATION – I understand that the selection of a benefit and the indication that a premium is to be paid does not necessarily include me in the insurance portions of this program.  In most instances an application for insurance must also be completed.  This election form will remain in effect and cannot be revoked or changed during the Plan Year, unless the revocation and new election are due to and consistent with a Change in Family Status (Examples: marriage, divorce, birth, death, adoption or applicable employment changes of spouse or employee).  Further, I understand that if I fail to complete, sign & file an election form during the open enrollment period, I will have been deemed to have elected to continue the benefit selections for the prior plan year and may have additional payroll deductions to fund the prior plan year elections.  DEDUCTION AUTHORIZATION: If applicable, I authorize my employer to deduct from my wages the required dues. NON-PARTICIPATING PROVIDER: I understand that I am responsible for a greater portion of my medical costs when I use a non-participating provider. HIV TESTING PROHIBITED: California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance. EFFECTIVE DATE: The effective date of coverage is subject to Anthem Blue Cross approval. ARBITRATION AGREEMENT: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by lawsuit or resort to court process except as California law provides for judicial review or arbitration proceedings.  Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.  Blue Cross/BC Life & Health and the member also agree to give up any right to pursue on a class basis any claim or controversy against the other. For more information regarding binding arbitration, please refer to your Evidence of Coverage/Certificate.  I attest by signing below that I have reviewed the information provided on this application and to the best of my knowledge and belief, it is true and accurate with no omissions or misstatements.  CERTIFICATION - I certify the above information to be correct and true and any dependents for which I have selected the dependent care benefit reside with me in a parent-child relationship and/or are legally dependent on me for their support.  I understand that any amounts remaining in my account(s) not used for eligible expenses incurred during the Plan Year will be forfeited in accordance with current Plan provisions and tax laws.  I authorize the deduction of the administrative fee, if applicable.
Employee Signature: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date:
Waive Coverage - To be eligible for waiver, you must meet one of the following:
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Waive Coverage? |  |  | Waived Benefits
You are covered by your spouse's employer plan (verification is required): |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Medical |  |  |  | Vision |  |  |  | Dental
You have an individual employment agreement with the City that allows you to waive coverage: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Medical |  |  |  | Vision |  |  |  | Dental
Important: I understand the benefit(s) I am waiving and that the City of Merced is not responsible for any medical and/or dental and/or vision expenses incurred by me and/or my dependents during the period in which these benefits are waived. I also understand that my next opportunity to re-enroll in the City of Merced medical, dental, and/or vision plan will be during the Open Enrollment period for the next calendar year or based on an eligible mid-year election change event.
Employee Signature: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date:
 |  |  |  |  |  | City of Merced
 |  |  |  |  |  | 2014 Open Enrollment Election Worksheet
EE#: |  |  |  |  |  | Effective Date: 01/01/2014
MEDICAL ELECTION
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Biweekly Medical Contribution
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Choose your Election in the dropdown list below |  |  |  |  |  |  |  | Biweekly Premium |  |  | Medical Allowance
 |  |  |  |  |  |  |  |  |  | Core |  |  | Buy-Up
Medical |  |  | Employee Only
 |  |  | Employee +1
 |  |  | Employee +2
DENTAL, VISION, DISABILITY & LIFE ELECTIONS
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Dental, Vision, Disability & Life Allowance:
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Choose your Elections in the dropdown lists below |  |  |  |  |  |  |  |  |  |  |  |  |  | Biweekly Premium
 |  |  |  |  |  |  |  |  |  | Core |  |  | Buy-Up
Dental |  |  | Employee Only
 |  |  | Employee +1
 |  |  | Employee +2
Vision |  |  | Employee Only
 |  |  | Employee +1
 |  |  | Employee +2
Disability
Life
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Dental, Vision, Disability & Life Subtotal:
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Dental, Vision, Disability & Life Allowance:
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Dental, Vision, Disability & Life Contribution:
OPTIONAL BUY UP PLAN ELECTIONS - Post-Tax
Disability Buy-Up (Post-tax) |  |  |  |  |  |  |  |  |  |  | (Yes/No)
Life Buy-Up - Employee (Post-tax) |  |  |  |  |  |  |  |  | Your Age: |  |  |  |  |  |  | Additional Life Insurance:
Life Buy-Up - Spouse (Post-tax) |  |  |  |  |  |  |  |  | Spouse's Age: |  |  |  |  |  |  | Additional Life Insurance:
Life Buy-Up - Dependent Child (Post-tax) |  |  |  |  |  |  |  |  |  |  |  |  | (Yes/No)
*Life Buy-Up for Spouse can not exceed 50% of the Employee Buy-Up amount.  You must elect [NAME] for yourself if you would like [NAME] on Spouse/Dependent Child. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Disability & Life Post-Tax Deduction:
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Your Biweekly Contributions
Payroll Use Only |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Biweekly Medical Premium:
Bi-weekly Subtotal-Required Coverage |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Biweekly Dental, Vision, Disability & Life Premium:
Less Bi-weekly Allowance |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Biweekly Premium Subtotal:
Subtotal Contribution (Credit) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Biweekly Allowance:
Pre-Tax Amount (PP) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Biweekly Pre-Tax Contribution:
Cash Back (CB) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Total Biweekly Post-Tax Contribution:
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Personnel: |  |  | AC: |  |  | Core Allowance: |  |  |  |  |  | Benefit Code:
AFSCME |  |  |  | Core Employee Only - $217.85 |  |  |  |  |  |  |  |  | Dental Core Employee Only - $22.11 |  |  |  |  |  |  |  |  |  | Vision Core Employee Only - $4.85
MACE |  |  |  | Core Employee +1 - $445.85 |  |  |  |  |  |  |  |  | Dental Core Employee +1 - $38.40 |  |  |  |  |  |  |  |  |  | Vision Core Employee +1 - $4.85
FD |  |  |  | Core Employee +2 - $655.38 |  |  |  |  |  |  |  |  | Dental Core Employee +2 - $62.31 |  |  |  |  |  |  |  |  |  | Vision Core Employee +2 - $4.85
MPOA |  |  |  | Buy-Up Employee Only - $234.92 |  |  |  |  |  |  |  |  | Dental Buy-Up Employee Only - $28.34 |  |  |  |  |  |  |  |  |  | Vision Buy-Up Employee Only - $8.73
SGTS |  |  |  | Buy-Up Employee +1 - $480.00 |  |  |  |  |  |  |  |  | Dental Buy-Up Employee +1 - $49.25 |  |  |  |  |  |  |  |  |  | Vision Buy-Up Employee +1 - $8.73
MC/MS |  |  |  | Buy-Up Employee +2 - $706.15 |  |  |  |  |  |  |  |  | Dental Buy-Up Employee +2 - $79.94 |  |  |  |  |  |  |  |  |  | Vision Buy-Up Employee +2 - $8.73
MM/MX
2014 - Biweekly Rates
 |  | MEDICAL |  |  |  |  |  | DENTAL |  |  |  |  |  | VISION |  |  |  |  |  | LIFE |  |  | STD/LTD
 |  | Core |  |  | Buy-Up |  |  | Core |  |  | Buy-Up |  |  | Core |  |  | Buy-Up
EE Only |  | 217.85 |  |  | 234.92 |  |  | 22.11 |  |  | 28.34 |  |  | 4.85 |  |  | 8.73 |  |  | 2.57 |  |  | 6.23
EE+1 |  | 445.85 |  |  | 480 |  |  | 38.4 |  |  | 49.25
EE+2 |  | 655.38 |  |  | 706.15 |  |  | 62.31 |  |  | 79.94
2014 Medical Allowances
 |  |  |  |  | AFSCME |  |  | MACE |  |  | FD |  |  | MPOA |  |  | SGTS |  |  | MC/MS |  |  | MM/MX
EE Only |  |  |  |  | 200.42 |  |  | 200.97 |  |  | 197.87 |  |  | 200.97 |  |  | 200.97 |  |  | 200.64 |  |  | 200.64
EE +1 |  |  |  |  | 410.18 |  |  | 411.3700000000001 |  |  | 404.7 |  |  | 411.3700000000001 |  |  | 411.3700000000001 |  |  | 410.66 |  |  | 410.66
EE +2 |  |  |  |  | 602.95 |  |  | 604.68 |  |  | 594.93 |  |  | 604.68 |  |  | 604.68 |  |  | 603.65 |  |  | 603.65
2013 All Other Premiums Allowance
 |  |  |  |  | AFSCME |  |  | MACE |  |  | FD |  |  | MPOA |  |  | SGTS |  |  | MC/MS |  |  | MM/MX
EE Only |  |  |  |  | 32.9 |  |  | 32.55000000000001 |  |  | 32.55000000000001 |  |  | 32.55000000000001 |  |  | 32.55000000000001 |  |  | 32.76000000000001 |  |  | 32.76000000000001
EE +1 |  |  |  |  | 47.89 |  |  | 47.31 |  |  | 47.31 |  |  | 47.31 |  |  | 47.31 |  |  | 47.68 |  |  | 47.68
EE +2 |  |  |  |  | 69.88 |  |  | 68.99000000000001 |  |  | 68.99000000000001 |  |  | 68.99000000000001 |  |  | 68.99000000000001 |  |  | 69.58000000000001 |  |  | 69.58000000000001
[NAME]
Benefits:
CORE PLAN
STD | 0.6 |  | 600 |  |  | maximum benefit per week |  |  |  |  |  |  | Maximum weekly covered salary:
LTD | 0.6 |  | 2500 |  |  | maximum benefit per month |  |  |  |  |  |  | Maximum monthly covered salary:
BUY-UP PLAN
STD | 0.6667 |  | 1650 |  |  | maximum benefit per week |  |  |  |  |  |  | Maximum weekly covered salary:
LTD | 0.6667 |  | 7000 |  |  | maximum benefit per month |  |  |  |  |  |  | Maximum monthly covered salary:
Rates:
CORE PLAN
STD Premium Rate per $100 of covered salary is: |  |  |  |  |  |  |  |  |  |  |  | 0.138 |  |  | per month
LTD Premium Rate per $100 of covered salary is: |  |  |  |  |  |  |  |  |  |  |  | 0.194 |  |  | per month
BUY-UP PLAN
STD Premium Rate per $100 of covered salary is: |  |  |  |  |  |  |  |  |  |  |  | 0.08 |  |  | per month
LTD Premium Rate per $100 of covered salary is: |  |  |  |  |  |  |  |  |  |  |  | 0.173 |  |  | per month
LIFE & AD&D |  |  |  |  |  | Disability Buy-Up Option
Monthly Rates - 2013
Life |  |  |  |  |  | Yes
AD&D
VOLUNTARY EMPLOYEE LIFE AND AD&D BUY-UP |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | VOLUNTARY SPOUSE LIFE AND AD&D BUY-UP
AMOUNT |  |  | 10000 |  |  | 20000 |  |  | 40000 |  |  | 60000 |  |  | 80000 |  |  | 100000 |  |  |  |  |  | 5000 |  |  | 10000 |  |  | 20000 |  |  | 30000 |  |  | 40000 |  |  | 50000
0-29 |  |  | 0.4153846153846154 |  |  | 0.8307692307692307 |  |  | 1.661538461538461 |  |  | 2.492307692307693 |  |  | 3.323076923076923 |  |  | 4.153846153846154 |  |  |  |  |  | 0.2076923076923077 |  |  | 0.4153846153846154 |  |  | 0.8307692307692307 |  |  | 1.246153846153846 |  |  | 1.661538461538461 |  |  | 2.076923076923077 |  |  |  | 10000 | 5000
30-34 |  |  | 0.4615384615384616 |  |  | 0.9230769230769231 |  |  | 1.846153846153846 |  |  | 2.769230769230769 |  |  | 3.692307692307693 |  |  | 4.615384615384615 |  |  |  |  |  | 0.2307692307692308 |  |  | 0.4615384615384616 |  |  | 0.9230769230769231 |  |  | 1.384615384615385 |  |  | 1.846153846153846 |  |  | 2.307692307692307 |  |  |  | 20000 | 10000
35-39 |  |  | 0.5538461538461538 |  |  | 1.107692307692308 |  |  | 2.215384615384615 |  |  | 3.323076923076923 |  |  | 4.43076923076923 |  |  | 5.538461538461538 |  |  |  |  |  | 0.2769230769230769 |  |  | 0.5538461538461538 |  |  | 1.107692307692308 |  |  | 1.661538461538462 |  |  | 2.215384615384615 |  |  | 2.769230769230769 |  |  |  | 40000 | 20000
40-44 |  |  | 0.8307692307692308 |  |  | 1.661538461538462 |  |  | 3.323076923076923 |  |  | 4.984615384615386 |  |  | 6.646153846153847 |  |  | 8.307692307692308 |  |  |  |  |  | 0.4153846153846154 |  |  | 0.8307692307692308 |  |  | 1.661538461538462 |  |  | 2.492307692307693 |  |  | 3.323076923076923 |  |  | 4.153846153846154 |  |  |  | 60000 | 30000
45-49 |  |  | 1.292307692307692 |  |  | 2.584615384615384 |  |  | 5.169230769230769 |  |  | 7.753846153846155 |  |  | 10.33846153846154 |  |  | 12.92307692307692 |  |  |  |  |  | 0.6461538461538461 |  |  | 1.292307692307692 |  |  | 2.584615384615384 |  |  | 3.876923076923077 |  |  | 5.169230769230769 |  |  | 6.461538461538462 |  |  |  | 80000 | 40000
50-54 |  |  | 1.846153846153846 |  |  | 3.692307692307693 |  |  | 7.384615384615385 |  |  | 11.07692307692308 |  |  | 14.76923076923077 |  |  | 18.46153846153846 |  |  |  |  |  | 0.9230769230769231 |  |  | 1.846153846153846 |  |  | 3.692307692307693 |  |  | 5.538461538461538 |  |  | 7.384615384615385 |  |  | 9.23076923076923 |  |  |  | 100000 | 50000
55-59 |  |  | 2.723076923076924 |  |  | 5.446153846153847 |  |  | 10.89230769230769 |  |  | 16.33846153846154 |  |  | 21.78461538461539 |  |  | 27.23076923076923 |  |  |  |  |  | 1.361538461538462 |  |  | 2.723076923076924 |  |  | 5.446153846153847 |  |  | 8.169230769230769 |  |  | 10.89230769230769 |  |  | 13.61538461538462
60-64 |  |  | 4.338461538461539 |  |  | 8.676923076923078 |  |  | 17.35384615384616 |  |  | 26.03076923076923 |  |  | 34.70769230769231 |  |  | 43.38461538461539 |  |  |  |  |  | 2.16923076923077 |  |  | 4.338461538461539 |  |  | 8.676923076923078 |  |  | 13.01538461538462 |  |  | 17.35384615384616 |  |  | 21.69230769230769
65-69 |  |  | 7.707692307692307 |  |  | 15.41538461538461 |  |  | 30.83076923076923 |  |  | 46.24615384615385 |  |  | 61.66153846153846 |  |  | 77.07692307692308 |  |  |  |  |  | 3.853846153846153 |  |  | 7.707692307692307 |  |  | 15.41538461538461 |  |  | 23.12307692307693 |  |  | 30.83076923076923 |  |  | 38.53846153846154
70-74 |  |  | 10.89230769230769 |  |  | 21.78461538461539 |  |  | 43.56923076923078 |  |  | 65.35384615384616 |  |  | 87.13846153846156 |  |  | 108.9230769230769 |  |  |  |  |  | 5.446153846153847 |  |  | 10.89230769230769 |  |  | 21.78461538461539 |  |  | 32.67692307692308 |  |  | 43.56923076923078 |  |  | 54.46153846153846
75-99 |  |  | 23.3076923076923 |  |  | 46.61538461538461 |  |  | 93.23076923076921 |  |  | 139.8461538461538 |  |  | 186.4615384615384 |  |  | 233.076923076923 |  |  |  |  |  | 11.65384615384615 |  |  | 23.3076923076923 |  |  | 46.61538461538461 |  |  | 69.92307692307692 |  |  | 93.23076923076921 |  |  | 116.5384615384615
Employee Life Buy-Up |  |  |  |  |  |  | Spouse Life Buy-Up
10000 |  |  |  |  |  |  | 5000
20000 |  |  |  |  |  |  | 10000
40000 |  |  |  |  |  |  | 20000
60000 |  |  |  |  |  |  | 30000
80000 |  |  |  |  |  |  | 40000
100000 |  |  |  |  |  |  | 50000
EE-only |  |  |  |  |  |  | Anthem Blue Cross EPO - Low Plan |  |  |  |  |  |  |  |  | Dental PPO (CSAC) - CORE |  |  |  |  |  |  |  | VSP - Core
EE + Child |  |  |  |  |  |  | Anthem Blue Cross EPO - Buy Up |  |  |  |  |  |  |  |  | Dental PPO (CSAC) Buy-up |  |  |  |  |  |  |  | VSP - Buy-up
EE + Spouse
EE + Children
Full Family
Male |  |  | Single |  |  |  | Yes |  | Child
Female |  |  | Married |  |  |  | No |  | Spouse
 |  |  | Divorced |  |  |  |  |  | Domestic Partner
 |  |  | Separated |  |  |  |  |  | Step-child
 |  |  |  |  |  |  |  |  | Adopted Child
Benefit Codes
 |  |  | CD | CE | CF
 |  |  | CG | CH | CI
 |  |  | CP | CQ | CR
 |  |  | CJ | CK | CL
 |  |  | CM | CN | CO
 |  |  | CA | CB | CC
 |  |  | [NAME] | CW | CX