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UA Group Benefits Enrollment Form

Tuesday, October 15, 2019

Click here for the 2019 benefit rates.

Current Campus: UA - Pulaski Technical College

To be completed by Human Resources Department:  Effective Date:                               

Please complete all sections of this form. ALL FIELDS ARE REQUIRED. Remember, if you elect pre-tax contributions, you may not change your medical, dental or vision elections until the next election period unless you have a change in family status.

Enter the last four numbers of your social security number.

Marital Status:
Employment Status:
Benefit changes for 2019?
Medical Plan
Dental Plan
Vision Plan
Your Contribution: Check which of your eligible contributions you would like to pay on a pre-tax basis under Section 125.
Optional Accidental Death & Dismemberment: You may choose coverage for yourself in $25,000 increments (maximum of $300,000) not to exceed 15 times your annual salary. Family coverage pays benefits for your spouse at 60% of employee amount and each child at 20%.
Optional Life Insurance: This is in addition to the Basic Life Insurance provided by the University, and the maximum benefit is $500,000.
Dependent Life Insurance: You may also purchase dependent life coverage on your eligible dependents. Each child is covered for 50% of the spouse amount elected below. (Children ages 14 days-6 months are covered for $1,000)
Optional Long Term Disability: This is available to employees with salaries over $20,000 in addition to the Basic Long Term Disability provided by the University.

List below the individual(s) you designate to receive proceeds from your Basic Life Insurance, Optional Life Insurance (if elected), and Optional Accidental Death & Dismemberment Insurance (if elected). Unless otherwise indicated, payment will be made equally to all persons named. If no beneficiary is living at the time of distribution, payment will be made according to the policy terms. This supersedes any other beneficiary designation. The employee is the beneficiary of all dependent death benefits.

Benefit Codes:
Benefit Codes:
Benefit Codes:
Benefit Codes:

**AUTHORIZATION - I have read the enrollment materials and understand the benefit selections and beneficiary designations I have made on this form. I have had the opportunity to accept or decline coverage. I have been informed about my fringe benefit options, and I understand the effective dates, coverage and premiums. I understand that if I elect family (or dependent) coverage under any university plan, I may not be covered both as an employee and as a dependent under another University of Arkansas employee’s plan and that dependent children may be covered only under one parents plan but not both. I understand I have 31 days from my date of hire to make decisions concerning my benefit elections, and I can change my benefit elections at any time during my first 31 days of employment. I understand my application must be received by Human Resources within 31 days of hire. If I do not elect life and/or LTD coverage within 31 days of hire, I (along with my eligible spouse and/or dependents) will be subject to evidence of insurability requirements. I understand I cannot choose medical and/or dental coverage after 31 days of hire unless I have a qualified family status change or qualified loss of other coverage. If I gain a dependent through marriage, birth, adoption or placement for adoption, I may enroll myself, my spouse and dependent(s) within 31 days. I have been given the opportunity to ask questions, and I understand I may call or visit my Human Resources Office if I have any future questions or concerns. I authorize my employer to deduct from my wages or salary the amount of contributions, if any, required for the benefits I have selected.**

I understand that typing my full name in this box constitutes a legal signature confirming that I acknowledge and agree to the authorization terms above.

Benefits Representative:        __________________________________________________________________

Date: ___________________________