Open Enrollment Worksheet.xls by parpar

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									Employee Benefits Open Enrollment Worksheet                                                              Employee Information
Be sure you have your log in ID and password before you begin the on-line Open Enrollment process.       Your Name:
                                                                                                         NIS Employee Number:
                                                                                                         Social Security # (Tax ID):
Dependent and Beneficiary Information:
(The NIS system will assign a new address book number to non-employees.)

  Name: (First, MI, Last)                                                                                Name: (First, MI, Last)
  Social Security #: (or enter NEWBORN)                                                                  Social Security #: (or enter NEWBORN)
  Phone #:                                                                                               Phone #:
  E-mail:                                                                                                E-mail:

  Street Address:                                                                                        Street Address:

  City, State, Postal Code:                                                                              City, State, Postal Code:

  Gender:                            M     F                                                             Gender:                        M    F
  Relationship:                      Spouse OR Child/Stepchild                                           Relationship:                  Spouse OR Child/Stepchild
  If Child/Stepchild, please complete the following:                                                     If Child/Stepchild, please complete the following:
  High School Graduate?              Y      N      Legally Disabled?          Y      N                   High School Graduate?          Y     N     Legally Disabled?    Y     N
  Employed?                          Y      N      Date of Disability                                    Employed?                      Y     N     Date of Disability

  Full Time Student?                 Y      N      Date of Medicare                                      Full Time Student?             Y     N     Date of Medicare
  Post High School Attending:                                                                            Post High School Attending:


  Name: (First, MI, Last)                                                                                Name: (First, MI, Last)
  Social Security #: (or enter NEWBORN)                                                                  Social Security #: (or enter NEWBORN)
  Phone #:                                                                                               Phone #:
  E-mail:                                                                                                E-mail:

  Street Address:                                                                                        Street Address:

  City, State, Postal Code:                                                                              City, State, Postal Code:

  Gender:                            M     F                                                             Gender:                        M    F

  Relationship:                      Spouse OR Child/Stepchild                                           Relationship:                  Spouse OR Child/Stepchild

  If Child/Stepchild, please complete the following:                                                     If Child/Stepchild, please complete the following:

  High School Graduate?              Y      N      Legally Disabled?          Y      N                   High School Graduate?          Y     N     Legally Disabled?    Y     N

  Employed?                          Y      N      Date of Disability                                    Employed?                      Y     N     Date of Disability

  Full Time Student?                 Y      N      Date of Medicare                                      Full Time Student?             Y     N     Date of Medicare

  Post High School Attending:                                                                            Post High School Attending:

  Benefit Options 2009 -- Shortened Plan Year: The Guide is not intended to provide in-depth information about the plans. For further details, consult Summary Plan Descriptions on our website:
                                                                                     www.das.state.ne.us/personnel/benefits

                                                State Employee Benefits / Phone: (402) 471-4443 (inside Lincoln) or (877) 721-2228 (outside Lincoln)
                                        STATE EMPLOYEE




                                                                                                                                              Employee + Dependent
                                                                                                                                              Child(ren) ( Four Party




                                                                                                                                                                                Employee + Spouse +
                                                                                                                 (Two Party Coverage)




                                                                                                                                                                                Dependent Child(ren)
                                        BENEFIT CHOICES




                                                                                                                 Employee + Spouse




                                                                                                                                                                                (Family Coverage)
                                                                                    (Single Coverage)
                                          WORKSHEET




                                                                                    Employee Only




                                                                                                                                              Coverage)
MEDICAL:        BlueCross BlueShield of Nebraska
                      Regular PPO
                      High Deductible PPO
                      BlueChoice (POS)
                      BlueSelect (HMO)

DENTAL:         Ameritas

VISION:         VSP
                      Basic Vision
                      Premium Vision

LIFE INSURANCE: Mutual of Omaha
                      Basic $20,000 Life - Automatic for full-time employees, paid by the State
                      Basic $20,000 Life - Optional for part-time eligible employees at a minimal cost:                                 Yes                                No
                      Supplemental Life:                  Flat $5,000                OR                     Flat $10,000                            OR
                      (select only 1)                     1 x Annual Salary          OR                     2 x Annual Salary                       OR                     3 x Annual Salary           OR
                                                          4 x Annual Salary          OR                     5 x Annual Salary
                      Optional Dependent Life:                                Low Option                    High Option
                      Accidental Death & Dismemberment:                       Yes                           No

LONG-TERM DISABILITY:
                MetLife (see page 16)                     Option 1            Option 2                      Option 3                    Option 4
                      (select only 1)                     Option 5            Option 6                      Option 7                    Option 8

FLEXIBLE SPENDING ACCOUNTS:
                ASI (see page 11)
                      Annual estimated expenses for services rendered during the upcoming shortened plan year (January 1 - June 30, 2009)
                      that will not be reimbursed by your medical and / or dental plans:
                                  Deductible, copays & coinsurance                                      $
                                  Routine office visits                                                 $
                                  Non-covered prescriptions                                             $
                                  Hearing Aids                                                          $
                                  Over-the-counter medications                                          $
                                  Chiropractic expenses                                                 $                                                               Benefit Options 2009 -- Shortened Plan Year:
                                  Eyeglasses / Contact lenses expense                                   $                                                               The Guide is not intended to provide in-depth
                                  Dental Work                                                           $                                                               information about the plans. For further details,
                      TOTAL ANNUAL MEDICAL EXPENSES:                                                    $                                                               consult Summary Plan Descriptions on our website:
                      Amount Per Pay Period (bi-weekly 12 or monthly 6)
                      A    t P P P i d (bi         kl           thl                                     $                                                               www.das.state.ne.us/personnel/benefits
                                                                                                                                                                        www das state ne us/personnel/benefits
                                        State Employee Benefits / Phone (402) 471-4443 (inside Lincoln) or (877) 721-2228 (outside Lincoln)

								
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