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					                                                                                                  Broward Health
                                                                                                  Short Term Disability Insurance and
                                                                                                  Long Term Disability Insurance
                                                                                                  Enrollment Form
                                                                                                  Policy: Hartford Life & Accident Ins. Co.

 Employee Name:                                                                        Occupation:

 Social Security Number: __ __ __ - __ __ - __ __ __ __                                Date of Birth: __ __/__ __/__ __ __ __

 Employee #:                                                                           Gender:              Annual Salary:

 Date of Hire: __ __/__ __/__ __ __ __                                                 Effective Date:



                                Short Term Disability Insurance Plan – Rate Per $100 of Coverage = .72 cents
 To calculate the per-paycheck cost for STD coverage, please complete the calculations below.
 NOTE: If your annual base salary exceeds $86,666, use $86,666 as your annual salary in the calculation.

 ____________ ÷ 100 = ____________ X                             .72 cents            = ___________             ÷        26      = ________________
 Annual Salary                                                 Your Rate                                                         Cost per Paycheck
                                                                                                                        (cost may vary slightly due to rounding)

          Yes**, I would like to participate in the STD plan subject to pre-existing condition limitation. I authorize Broward Health to
           deduct from my wages the necessary premium for this coverage.

          No, I do not wish to participate in the STD plan. I understand that evidence of insurability may be required, at my own
           expense, if I decide to elect this coverage in the future.

Employee Signature: ________________________________________                                      Date: __ __/__ __/__ __ __ __



                             Long Term Disability Insurance Plan – Rate Per $100 of Coverage = $1.02 (half paid by NBHD)
 To calculate the per-paycheck cost for LTD coverage, please complete the calculations below.
 NOTE: If your annual base salary exceeds $100,000, use $100,000 as your annual salary in the calculation. Note: Managers and
 Physicians are automatically enrolled in LTD subject to other plan provisions.

 ____________ ÷ 100 = ________ X $1.02    =                               _________         ÷      26       ÷       2           =           _________________
 Annual Salary                  Your Rate                                                                                                     Cost per Paycheck
                                                                                                                                (cost may vary slightly due to rounding)

          Yes**, I would like to participate in the LTD plan subject to pre-existing condition limitation. I authorize Broward Health to
           deduct from my wages the necessary premium for this coverage.

          No, I do not wish to participate in the LTD plan. I understand that evidence of insurability may be required, at my own
           expense, if I decide to elect this coverage in the future.

Employee Signature: ________________________________________                                      Date: __ __/__ __/__ __ __ __



** I understand the effective date of my coverage will be delayed if I am not in active employment because of an injury, sickness, temporary lay-off or leave of
    absence on the date this insurance would otherwise become effective. The insurance will go into effect and remain in effect only in accordance with the
    provisions, terms and conditions of the insurance policy which is issued to your employer. I have also read and understand the information in the Benefit
    Highlight Sheets, including all statements regarding exclusions, benefit amounts, pre-existing conditions limitations, duration and offsets. In the event of any
    difference between the enrollment form and the insurance policy, I agree to be bound by the insurance policy.

Updated: 10/08


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posted:9/29/2012
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