Inclusive language Summary of Human Resources New Hire Forms by xqz12573


									Inclusive language: Summary of Human Resources New Hire Forms

Mary Lucal

Summary: In general, given the number of forms new employees must complete, the areas of
concern are relatively few.   I have broken this summary down into areas, and indicated the
exact forms that might need to be changed.        Other areas where I expected to find some
troublesome language {for example, in designation of beneficiary areas} I did not encounter it.

Use of gender-specific language

This was the area of most common concern. Many forms {I've indicated them below} ask the
new hire or applicant to identify their sex {M/F} or gender. This may represent an obstacle for
transsexual individuals or those in transition. The following forms containing this language:

Application for employment

Knoxville Police Record Request

EEO Form

Personal Data Form

LongTerm Disability Enrollment Form

State of TN Group Insurance Enrollment/Change Application

State of TN Optional Group Special Accident Program Enrollment Card

State of TN Optional Term Life Insurance Employee Handbook

Suggested change: For discussion. Have any peer institutions adopted more inclusive language
in this area? What might be a better format to gather this information?

Marital status

Other forms ask new employees to indicate whether they are married or single.           No other
option is available for those who may be in other significant relationships or have live-in
companions. The following forms request this information:

     Personal Data Form (married/single)

     State of TN Enrollment/Change Application (extensive spousal information requested for
     coverage purposes)

     State of TN Insurance Handbook (contains provision on page 9 specifically excluding "live-in
     companions who are not legally married to the employee")

     State of TN Optional Term Life Employee Handbook (allows for spousal and child coverage only)

     Suggested change: Married-single-domestic partner-other



I, the undersigned consumer, do hereby authorize the University ofTennessee by and through its independent contractor,
KROLL BACKGROUND AMERICA, INC. ("KBA''), to procure a consumer report and/or investigative consumer
report on me. I understand that this authorization and release shall be valid for subsequent consumer and/or investigative
consumer reports during my period of employment with the University ofTennessee for the purpose of investigating any
incidents of workplace misconduct or criminal activity for which I am alleged to have been involved during my

These above-mentioned reports may include, but are not limited to, information as to my character, general reputation,
and personal characteristics, discerned through employment and education verifications; personal references; personal
interviews; my personal credit history based on reports from any credit bureau; my driving history, including any traffic
citations; a social security number verification; present and former addresses; criminal and civil history/records; any other
public record.

I further authorize any person, business entity or governmental agency who may have information relevant to the above to
disclose the same to the University ofTennessee by and through KBA, including, but not limited to any and all courts,
public agencies, law enforcement agencies and credit bureaus, regardless of whether such person, business entity or
governmental agency compiled the information itself or received it from other sources.

I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer
report of which I am the subject upon my written request to KBA, if such is made within a reasonable time after the date
hereof. I also understand that I may receive a written summary of my rights under 15 U.S.C. § 1681et. seq.

Signature:                                                                    _              Date:- - - - - - -


                               First                                     Middle                                   Last

Other Names Used (alias, maiden, nickname)                                                                                                          _

YEARS USED                                                 _

Address:                                 --,--                 --=-                 ,..,....---:-----,:---------::---­
            Street/P. O. Box             City                   State              Zip Code             County                         Dates

             Street /P. O. Box           City                                      Zip Code             County                         Dates

Social Security Number:                                                       Daytime Telephone Number:                                                 _

Driver's License Number:                                  State oflssuance:              *Date of Birth:                         *Gender                _

•    This Inrormation will enable us to properly identif'y you In tbe event we find adverse Idormation during tbe course orour background search.



PERSONIBUSINESS REQUESTING BACKGROUND CHECK                                   The University of Tennessee

           LAST                                 FIRST                            MIDDLE                         MAIDEN

ALIASES                                                               SOCIAL SECURITY #                                    _

ADDRESS --,----~-,-------------------------_c_--­

DATEOFBIRTH.                                             SEX-                         RACE,                                _

DRIVERS LICENSE #                                                   STATE                     STATUS                       _

I hereby authorize the KnoxvillePoliceDepartment to release copies of my arrestrecords to the person namedabove.


                        IIl'luiryJ\.e~l,!I1S.                                                l'to1¥l~t.iQ.q

                                                                 County of
JIMS Computer Check                                              Personally appeared before me,

No RecordFound
                                                                 with whom I am personally acquainted, and who
RecordFound                                                      acknowledged that he/she executed the within instrument
                                                                 for the purposes thereincontained.
Computer Generated Arrest History AttachedY __ N __
Record Checked by:                                               Witness my hand,at office,this

                                                                 Dayof                                    ,20

                                                                 Notary Public

Date:                                                            My commission expires:

                                                                                     KP-AD-REC (4/04) 048/RO

                               THE UNIVERSITY OF TENNESSEE


The University of Tennessee Knoxville area units are committed to equal employment opportunity and affirmative action.
The University of Tennessee is required by the U.S. Department of Labor to request and maintain the following data on all
applicants for employment with the University. This information will be used for statistical summaries of employment
practices, and to monitorthe University's compliance with equal employment opportunity and affirmative action
requirements. Your voluntary return of this form in the enclosed postage-paid envelope is encouraged.





4.      GENDER:          Male                 Female

5.      ETHNICITY:       Hispanic or Latino

                         Not Hispanic or Latino

6.      RACE:            American Indian/Alaskan Native


                         Blackor AfricanAmerican


                         NativeHawaiian/Pacific Islander

7.      VETERAN STATUS (Check only If applicable):

        Vietnam Era Veteran (February 28,1961 - May 7,1975):

        OtherEligible Veteran:       _
                                                                                         (seereverse sidefor list)

        Fromwhatsourcedid you learn of this position?

        If by advertisement, please namepublication.

For Office Use:

Hiring Department/OffIce:

Requisition Number:

Position Title and Position Number:

Return to:

Human Resources - Employment
221 Conference Center Bldg.
Knoxville, TN 37996-4126                                                                                             8/03
                                                                                            FORORIENTATION ONLY


Form Of,t>:q~l~ss)                          Mr.             DMrs.                     D    Miss                     D       Ms.                   DDr.
e~~h:J~*\~:;' ,
                   ---------------- Middle Name
Known as                                                                                  Soc. Security #
                       (last name, fiist name middle name)
Birthdate                                                               (mmlddYwYJ        Gender                    D Male                        D Female
Nationality                                                                               Marital Status           D      Single                  D      Married

            Street                    ""'"'"'.....;...;.....;...;.....;...;                                           _
                                                                                                                               County                              _

                                                                                            Cell Phone (Optional),                   --------­
                                    Please Include Area Code                                                                         Please include Area Code
             Phone Release        o comPlete'lnfo~alion                           I   DNoAddress             D      No PIi,oni!lAddress
                                  D~~;Phane Number                                                           DNoPui>!i~'Listiiig

OFFICE ADDRESS (IT0006-5ubtype 3)                                                     Office Phone Release MUsTibe"Completed
          Building Name                                                                                                                   Building No.             _

          StreetAddress                                                                                                                   Room No.
          City                                                                                                                 County                              _
          state                                                                                    Zip          -:-'-:­         _           Mail stop              _
         Telephone                                                                                 Fax
                                    Please Include Area Code

            Phone Release    '*   DbomPlete Information                               DNoAddress                                                   *Required for

                                  []ril6Phone Number'                                                                                               Email Access

         City                                                                                   State-'-.---­
         Telephone                _ _ _ _ _ _ _ _ _ _ _ (Please includeArea Code)
                       ····&~lVPlgFl;11Qclcs forallceverages:
                           '"."I.V"," '···"··""'.:J,,')I:L   ,'c.;, ,"',',,',.,                      ,

 Social Security Number                                                           Name (last, first, middle initial)

 Date of Birth                                                                       Coverage Effective Date:            Date of Hire
             /         /                                                                     /           /                       /        /
 0    Male                                                                           Responsible Account:                Pay Cycle:
 0    Female

 Plan Features                                   o PlanA                                            o Plan B                   o PlanC
 Income Replacement                              662/3%                                             63%                        60%
 Waiting Period                                  4 Months                                           4 Months                   4 Months
 Alcohol and Drug                                2 Years                                            2 Years                    2 Years
 Abuse Treatment
 Annuity                                         15%                                                10%                        5%
 Cost of Living                                 3% after two years                                  3% after two years         3% after two year
 Premium per $100 of                            .680                                                .558                       .445
 covered salary
Minimum Monthly                                 $100                                                $100                       $50

     o	          I REQUEST COVERAGE under the Long Term Disability Insurance Plan I have
                 indicated above, through my employer's group insurance contract, as now or
                 hereafter applicable to me, and authorize the appropriate deductions from my

     o	          I DECLINE COVERAGE under the Long Term Disability Insurance Plan. I

                 understand that if I desire to apply at a later date for the benefits that I have

                 declined, I will have to furnish, at my own expense, proof of good health

                 satisfactory to Hartford Life before coverage can become effective.

     Date:                                                                           Signature of Employee:	                                       _

                  State of Tennessee • Department of Finance and Administration· Division of Insurance Administration
                  13th Floor, Williom R. Snodgrass TN Tower· Nashville, Tennessee 37243 • 615.741.3590 or 1.800.253.9981 • Fax: 615.741.8196

See back for complete instructions. You must sign and date this form, even if refusing coverage. Please print clearly.

Part 1 - Enrollment or Change Request (check 011 that opply)
ADD                                           CHANGE                                              TERMINATE                                    REASON
o Health                                      o Marital status                                    o  Coverage: self                            o Terminate employment
o Dental                                      o Beneficiary                                       o  Coverage: spouse                          o Employee request
                                              o Health Plan*                                      o  Coverage: child                           o Divorce
o New Eligible Employee                       o Dental Plan*                                                                                   o Child oge
o Spouse                                      o Type of Health Coverage'                          PLAN
                                                                                                                                               o Child married
o Child(ren) .                                o Type of Dentol Coverage'                          o Health                                     o Child no longer student
                                                                                                  o Dental                                     o Child no langer claimed on federal
o Special Enrollment Provision                    *indicote change in Port 3                      o Special Accident                             income tax
o Medical Underwriting                                                                                                                         o Death
Effective:                                        Date of chonge:                                 Terminotion Date:

Part 2 - Employee Information (must be completed, even if refusing coverage)
SOCiAl SECURITY NUMBER I LAST NAME                                                                I FIRST NAME                                                      MIDDLE INITIAL

STREET ADDRESS                                                                 APT t               CITY                                         STATE               ZJPCODE

CTY CODE· RESI DENCE          CTY CODE- WORK                 SEX             I BIRTHDATE                             MARITAL STATUS                                 BUDGET CODE
000                           000                            OM        OF                                            Os    OM        OD    Ow
DEPARTMENT NAME                                                                                                      ANNUAL SALARY                                  DATE HIRED


SOCIAL SECURITY NUMBER I NAME                                                                      DEPARTMENT

Part 3 - Enrollment Information
HEALTH                                                       TYPE            I OPTIONAL LIFE                         DENTAL                     TYPE

o PPO                                                        0     Single      10    Special Accident                o Prepoid                  o Employee Only
o POS         0    East   0    Middle    0   West            0     Family      o Term*                               OPPO                       o Employee + 1
o HMO*                                                       0     Split       0     Universal*                                                 o Employee 2 or more
*Additional form needed. Please contact your deportment's insurance preparer.

Part 4 - Dependent Information (see bock for definitions, attach a separate sheet if necessary)
SOCIAL SECURITY NUMBER I                         NAME
                                             LAST, FIRST, MI
                                                                             I      BIRTHDATE
                                                                                                  I   RELATIONSHIP
                                                                                                                     I   SEX     I   ACQUIRE
                                                                                                                                                  (AGE 19-24)
                                                                                                                                                                     HEALTH I DENTAl
                                                                                                                     OM OF                       OV ON

                                                                                                                     OM    OF                    OV ON

                                                                                                                     OM OF                       OV ON

                                                                                                                     OM    OF                    OV ON
Ifyour dependents (spouse and children) reside ot on oddress other than yours, please provide this information on on attachment.

Part 5 - Basic life Beneficiary Information
NAME                                                                                                                             rELATIONSHIP


Part 6 - Authorization
o   ACCEPT                    I confirm that 011 of the information provided above is accurate. I understand that knowingly providing false and/or misleading informa­
                              tion may subject me to disciplinary and/or legol oction and may result in lass of insuronce coverage. I authorize health care providers
                              to furnish' the insurance carrier with 011 medicol, admission, and insuronce records pertaining to me and my dependents. I understand
                              that if my dependent(s) become ineligible for coverage that I must report the chonge to my insuronce preparer within five working days. I
                              understand that all claims poid for ineligible dependents will be recovered. As the policy holder, I am responsible for claims payments to
                              my ineligible dependents.

o   REFUSAL                   I have been given the opportunity by my employer to apply for the Group Insurance Program and after due consideration, have decided
                              not to take advantage of this offer. I understand that if J later wish to apply, I or my dependents will have to provide proof of a special
                              enrollment provision or prove insurable through medical underwriting. I understand that the state does not have an open enrollment
                              period for health coverage.

I am currently enrolled in another health insurance pion: 0 Yes 0 No

A certificate of coverage letter must be provided to be exempt from the preexisting condition requirement.

I acknowledge receipt of my employee handbook and accept all the terms and conditions contained therin.

EMPLOYEE WORK TELEPHONE                                                                           I EMPLOYEE HOMETELEPHONE

 SIGNATURE                                                                                         DATE

FA-DB 20 (rev 11/06)                                                Return to your deportment's insurance preparer.                                                           RDASS-Dn

      Add:                     Check all appropriate boxes and include effective date. Effective date must be the first of the month.

      Change:                  Check desired change and include effective dote. Effective date must be the first of the month.

      Terminate/Plan:          Check all coverages to be cancelled. Effective date of termination is the last day of the month in which the event

                               causing termination occurred.
      Reason:                  Check the oppropriate reason for termination.

      Complete each line in full. County Cades are listed below. Ifyour spouse is a state employee, please complete the requested information
      about him/her.

      Health:	                 The nome of the HMO for which you are enrolling must be listed. If enrolling in a POS, check the box beside
                               the appropriate service area. A physician selection card must be completed for options noted with on
                               asterisk. Eligibility for an HMO or POS is based on your county of work or residence. These service areas
                               are listed in the Medical Plans Comparison Summary brochure. If enrolling in the PPO or POS, a certificate
                               of coverage letter must be provided to be exempt from the preexisting condition requirement.

      Type of Coveroge:	       Single covers employee only.
                               Family covers employee and all eligible dependents.
                               Single split covers a state pion employee whose spouse is also covered by the state pion.
                               Split covers a state plan employee and 011 eligible dependents if your spouse is also covered by the state plan with
                               single split coverage.

      Optional Life:	          Additional application forms are required to enroll in, terminate, increase or decrease coverage.

      Dental:	                 Coverage is optional. A dentist selection card must be completed for the prepaid plan.

      Anytime you elect to cover dependents, you must complete PART 4.

      Refer to your employee handbook for dependent eligibility rules. Ifyou elect to cover dependents, you must provide all information
      requested in Part 4 for each dependent. You must provide a social security number for any dependent two years of age or older. Ifyour
      dependents (spouse and children) reside at on address other than yours, please provide this infarmation on an attochment.

      RELATIONSHIP CODES                                                                       ACQUIRE DATE
      SP Legally married spouse                                                                Date of marriage
      CN Naturol child                                                                         Date of birth
      CN Legally adopted child                                                                 Date of placement for odoption
      CS Stepchild for whom you or your spa use has legal or joint custody or
          shored parenting                                                                     Dote custody obtained or marriage dote
      CL Any child living in your home for whom you are the legal guardian                     Date appointed guardian
      CT Any child you claim as a dependent for federal income tax                             Date you were able to claim child

      IMPORTANT; It is your responsibility to notify your insurance preparer of any changes in the eligibility status of a dependent within five
      working days of becoming ineligible.

      The fallowing are not eligible for coverage as your dependent through the State Group Insurance Program:
            Ex-spouse (even if court ordered).                                  • Married children, regardless of age.
            Parents of the employee or spouse.                                  • Foster children.
            Children in the armed forces on a full-time basis.                  • Live-in companions not legally married to the employee.
            Children over age 24 (unless they meet qualifications
            for incapacitation).

      Acquire Dotes are needed solely for the purposes of determining eligibility.

      STUDENT: Check Yes or No for any unmarried dependent child older than 18 years and 11 months of age. A full-time student is one who is
      registered for ot leost the number of credit hours that the institution requires in its definition of full-time student status and who attends
      classes for two of three semesters or three of four quarters in any 12-month period.

      COVERAGE HEALTH/DENTAL: Check block(s) to show coverage selected for each dependent.

      Ifyou enroll in on optional life program, a separate form must be completed to designate a beneficiary.

      Check a block either accepting or refusing coverage. You must sign and date the form.

                                                              COUNTY CODES
001 Anderson            017   Crockett          033   Hamilton           049    Lauderdale         065   Morgan              OB1   Stewart
002 Bedford             018   Cumberland        034   Hancock            050    Lawrence           066   Obion               082   Sullivan
003 Benton              019   Davidson          035   Hardeman           051    Lewis              067   Overton             OB3   Sumner
004 Bledsoe             020   Decatur           036   Hardin             052    Lincoln            068   Perry               084   Tipton
005 Blount              021   Dekalb            037   Hawkins            053    Loudon             069   Pickett             085   Trousdale
006 Bradley             022   Dickson           036   Haywood            054    McMinn             070   Polk                086   Unicoi
007 Campbell            023   Dyer              039   Henderson          055    McNairy            071   Putnam              087   Union
008 Connon              024   Fayette           040   Henry              056    Macon              072   Rhea                OBB   Von Buren
009 Carroll             025   Fentress          041   Hickmon            057    Madison            073   Raone               089   Warren
010 Carter              026   Franklin          042   Houston            058    Morion             074   Robertson           090   Washington
011 Cheatham            027   Gibsan            043   Humphreys          059    Marshall           075   Rutherford          091   Wayne
012 Chester             028   Giles             044   Jackson            060    Maury              076   Scott               092   Weakley
013 Claiborne           029   Groinger          045   Jefferson          061    Meigs              077   Sequatchie          093   White
014 Clay                030   Greene            046   Johnson            062    Monroe             078   Sevier              094   Williamson
015 Cocke               031   Grundy            047   Knox               063    Montgomery         079   Shelby              095   Wilson
016 Coffee              032   Hamblen           04B   Lake               064    Moore              080   Smith               096   Out of State
                                                                State of Tennessee
                                              Optional Group Special Accident Program Enrollment Card
Please Print
Full Name of Employee                                                             Social Security Number of Employee               Agency Code                         Hire Date

                  M w   Fj
                                    Birth Date of Employee
                                            f        I
                                                                     Name of Beneficiary                                           Social Security Number              Relationship

To insurevour elMb/e denendenfs, please provide the Infonnation reauestedbelow. See definitions at riaht                           Retationshio Codes .                Acculre Date
                                                           BirthDale     RelaUonshlp     Sex Acquire     Studenl                   SP legally married spouse           Dale of marriage
Sodal SecurltvNumber Name(Last, first Middle)              Mo DavYear Code               M/F Date        YIN
                                                                                                                                   CN natural or adopted child         Date of birth or
                                                                          I       I                                                                                    placement in
                                                                                                                                   CS stepchild for whom you or        home
                                                                                                                                   your spouse ha!i.11'l9al or joint
                                                                       I      I
                                                                              ,                                                    custody           ..                Date custody
                                                                                                                                    CL any child for Whom you are
                                                                      I       I                                                     the legal guardian                 Dale appointed
                                                                                                                                    CT any chl/d for whom you
                                                                      I       I                                                     provide support and claim as a     Dale you were
                                                                                                                                    dependent on.income tax            able to claim child
                                                                                                                                                                       on federal Income
                                                                      I       I                                                                                        tax

                                                                                  Employee Changes
Change name from:                                                                     '"        10: _~                                                                                    _

Change beneficiary to:                                                                          Relatlonshlp:                                                                                 _

Change type of coverage from:       o    Single or 0 Family                                     to:                                           ~---:--_==
o   I wish to terminate ccverage on myself.        o   I wish to terminate coverage on my dependent(s) as listed above.

Effective date of changes:                                                                 _    I hereby authorlz:e my employer to deduct from my salary (or wages) the required
                                                                                                Contribution for the Optional Special Accident Insurance for which I am, or may
                                                                                                become. englble under the group policy available to me as an employee of the
                                                                                                State of Tennessee.
Signalure                                                                  Date

                                                                                                Signature                                                              Date

Group Insurance Program

 Optional Term L~fe

Optional Universal Life

     SEPTEMBER 2005
How Do I Enroll?                                                                        Application for Optional Life Insurance (M-l)5202) to provide evidence of
                                                                                        insurability and be approved for coverage by UnumProvidenl.
New Employee
As a new employee you may enroll in one or both optional life insurance plans      (3)	 Minimum Issue is the least amount of coverage you can obtain. The
with coverage up to three (3) times your annual base salary WITHOUT                     minimum issue amount is $5,000 per plan.
providing evidence of insurability This opportunity is provided only to new        (4)	 Combination of Coverage. If you elect both the optional universal Iik'
employees and you must apply by the end of the first full calendar month of             insurance and the optional term life insurance, Yllur combined amount of
employment. u you do not enroll at this time, you cannot apply for coverage             coverage may not exceed three U) times your annual base salary tor
until the next annual enrollment transfer period. Evidence of insurability would        guaranteed issue or five (5) times for maximum issue not to exceed the
be required from you and any dependents you want to LOver.                              overall limit of $300,000.

Annual Enrollment Transjer Period                                                  The optional universal life insurance is available in $] ,OOl) increments. The
An annual enrollment transfer period for both optional life insurance plans will   optional term life insurance is available in 'li5,OOO increments.
take place in the fall of each year.
To apply for coverage or for additional amounts of coverage during the annual      Spouse coverage is available in $5,00l) increments of $5,000, S ll\l1l)O or
enrollment transfer period, Employees, Spouses and Children MUST ANSWER            $15,000. If your annual base salary is over S15.000 and your -;1'0Lbl' is UNDER
HEALTH QUESTIONS. There is no guarantee that the application for coverage          age 55, you are entitled to elect spouse coveragc equal to one ( Il [JITIL'S )'tlur
will be approved. Unuml'rovideni will determine if the applicants are insurable.   annual base salary to a maximum or $3l1,OOO.
In instances where an employee has not elected an amount of coverage equal to      If your spouse has been hospitalized. advised to seck medical trcatmcnt. or
the lesser of the salary based guarantee issue amount or $300,000, the             received disability benefits during the LIst six months, you must complete a
employee will be provided an opportunity to add up to $5,000 in life insurance     Supplemental Application for Optional Lilc Insurance (f\1-952021.
coverage without answering health questions.
How Much Coverage is Available?                                                    Dependent children can be insured lor S2,500 or $5,000 until the ;1,gL' of 24 and
                                                                                   as long as they remain eligible. Dependent children call be covered ()nly h\
Employee                                                                           ONE parent if both parents arc State employees.
The amount of coverage you may elect is determined by your annual base salary
(not including overtime pay, longevity, etc.) as of the date you sign your         Coverage for dependent children is not a stand-alone certifitntc. hut is pan ,)1
enrollment application.                                                            either an employee or spouse ccn ilicatc, nut both. II an I.'lllplo)'eL' ,II' Sp(luSe
                                                                                   certificate containing a childrcns term rider is cancelled, Cll\'LTagl' for th«
for the optional life insurance coverage there is a guaranteed issue amount, a     children is cancelled as well.
maximum issue amount and a minimum issue amount. If you elect both
insurances, then you can combine amounts of coverage.                              Calculating Guaranteed and Maximulll Issue Amounts
(1)	 Guaranteed Issue is the amount of insurance coverage you may elect            You can calculate your guaranteed and maximum issue amounts by fLlIlLl\\'ing
     without having to complete a supplemental application. You may elect up       these steps:
     to three (3) times your annual base salary regardless of your medical         (l)	 Determine your annual base salary by multiplying yuur m. )I1thl)' salary lJ\'
    history. This amount is available only to newly eligible employees.                 ] 2 (months) and round oIl to the nearest dollar.
(2)	 Maximum Issue is the largest amount of insurance coverage you can obtain.     (2)	 To calculate the GUARANTEED ISSUE AMOUNT, multiply )'l1llr annual
     You may elect up to five (5) times your annual base salary, subject to an          base salary from step I by 3, then round off that number to the ncx! higher
     overall limit of $300,000. To obtain any amount of insurance which is more         $5,000 increment. ".'
     than your guaranteed issue amount, you MUST complete a Supplemental

                                                                                   L--­                                       7


State of Tennessee
State and Higher Education Employees
November 2006
                                All dependentsmust be listed bynameon theappropriate enrollment/change applica­
                                tion. Benefits are not provided for dependents not listed on this form.A dependent
                                can only be coveredonce withinthe sameplan,butcan becovered undertwoseparate
                                plans (State, Local Education or Local Government).

 Full-time Student - One        Unmarried dependent children are eligible for coverage through the last day of the
 who is registeredfor at        month of their 24th birthday. Dependent children between the ages of 19 and 24
least the number ofcredit       must be Claimed on your incometax 01' be a full-time student. Proofof a dependent's
hours that the institution      eligibility may be required.
 requiresin its definition of
[ull-time student status and    Incapacitated children (mentally or physically disabled and incapable of earning a
who attends classesfor two      living) may continue health or dental, if applicable, coverage beyond age24 as long
ofthree semesters 01' three
                                as the incapacity existed before their 24th birthday and they were already insured
ofjour quarters in any 12­
                                under the state's group insurance program. The child must meet the requirements
month period.
                                for dependent eligibility previously listed. A request for extended coverage must
                                be provided to the Division of Insurance Administration within 90 days of the
                                dependent's 24th birthday. Additional proof may be requiredperiodically. Approval
                                of the incapacitationrequest is determined by theclaimsadministrator foryourhealth
                                insurance company. Coverage will not continueand will not be reinstated once the
                                child is no longer incapacitated.

What Dependents Are Not Eligible?
                                • Ex-spouse (even if court ordered)
                                • Manied children, regardless of age
                                • Parents of the employee or spouse (with theexception of long-tern] care)
                                • Foster children
                                • Children in the armed forces on a full-timebasis
                                • Children over age 24 (unless they meet qualifications for incapacitation)
                                • Live-in companions who are not legally married to the employee

How Do I Add Dependents to My Coverage?
                                An enrollment/change application should be completed within 60 days of the date
                                a dependent is acquired. The "acquire date" is the date of birth, marriage,changeof
                                student status, or, in case of adoption,the legalobligationand supportof such child.
                                Changes in type of coverage (single to family) are effective on the first day of the
                                month in which the dependent was acquiredor,if requested, the firstof thefollowing
                                month. If you maintained family coverage on the date the dependent was acquired,
                                the effective date may be retroactiveto the dependent's acquire date evenif beyond
                                the 60 day enrollment period.

                                An employee's child named under a qualifiedmedical support orde: must be added
                                within 60 days of the court order, if a court so stipulates. If covenng out-of-state
                                dependents, you must be enrolled in the Preferred ProviderOrganization (PPO).

  - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - [ I l l s u r a l l c e Handbook-=:2J
                                                                                        STATE OF TENNESSEE

                                                                                                OPTIONAL TERM LIFE ENROLLMENT APPLICATION

                                                                                                            ANNUAL ENROLLMENT 0 NEW HIRE
 EMPLOYEE· MUST ALWAYS BE COMPLETED                                                    SPOUSE· (Always show name - Fully Complete For Coverage)
 Please Print        (first)              (middle)                 (last)
            Please Print           (first)          (middle)                 (last)

 Residence Address                                   (streeUbox no.)                  Residence Address                                      (streeUbox no.)

 City                                     State                         Zip           City                                    State                          Zip

 Social Security Number                       -            -                          Social Security Number                     -                 -
 Birthdate                       Date of Hire                     Sex                 Birthdate                                                        Sex         _
 Budget Code                                                                          Has spouse been hospitalized, advised to seek medical treatment,
                               Daytime Phone No.
                                                                              -       or received disability benefits during the last 6 months?
 Employee Annual Base Salary $
                                                                                                            DYes 0 No
                                                                                      If yes, submit simplified application.
                                                  CERTIFICATE INFORMATION - SPOUSE

 Employee Coverage Amount: $
                                                         Spouse Coverage Amount: $                                      _
 Minimum: $5,000 Maximum: Five times your annual base salary.
                        Minimum - All Ages: $5,000
 Amounts over three times annual earnings subject to medical
                         Maximum - Less Than Age 55: $15,000 or one times employee
 evidence of insurability. All amounts adjusted to the next higher
                              annual base salary in multiples of $5,000 up to $30,000.
 multiple of $5,000 up to $300,000.
                                                  Maximum - Ages 55 and Over: $15,000

 Children's Coverage: 0 $2,500            o
                                        Children's Coverage: 0 $2,500 0 $5,000
 Coverage available on either employee or spouse certificate, but
                    Coverage available on either employee or spouse certificate, but not
 not both. However, if employee purchases coverage, children's
                       both. However, if employee purchases coverage, children's
 coverage must be attached to that certificate.
                                      coverage must be attached to that certificate.
 Beneficiary                                         Relationship
                    Beneficiary                                                Relatioriship

                List eligible dependent children as defined In the plan.
 COMPLETE                          Child's Name                               Social Security              Date of Birth      Issue        Sex         Relationship
 ONLY IF          (First)             (Middle)           (Last)                   Number                 Mo    Day       Yr   Age         M or F       to Employee
                The beneficiary of children's term Insurance is the employee, if llvinq, otherwise the estate of the covered child.

I certify that the information on this application is true and complete and that I am Actively at Work on the date of my signature
below. I understand that if I have selected insurance for myself, it will begin on the Certificate Issue Date; provided I am Actively
at Work on that date.

Dependent Spouse and/or Dependent Children's Coverage, if selected, will begin on the Certificate Issue Date; provided: (1) I
am Actively at Work on that date; and (2) my Dependent Spouse and/or Dependent Child(ren) is/are able to engage in normal
activities on the date the coverage is to become effective.

I understand that I, as the Employee, am the owner of all coverages applied for. I authorize my Employer to deduct the proper
premiums for this insurance from my earnings.

Employee Signature                                                       -:--:-:-:-:­                                  Date                                            _
                                                     FOR HOME OFFICE USE ONLY

DEDUCTION AMOUNT:                 E                                 S                                C                               TD                            _

M-95201 (Rev. 12-99)
Frequently Asked Questions (FAQs)

Q. Who Is Eligible For the PPO Plan Offered?                • View your benefits
A. Underthe PPO Plan you, your spouse and eligible          • Print an ID card
   dependents underthe age of zz, are eligible for          • Check your eligibility
   dental coverage. To review dependent eligibility,
   please referto your Employee Insurance                   • Check your claims
   Handbook. You may obtain a copy of this               • Contact Us By Phone
   handbook from your agency's insurance preparer.
                                                          Inside the Nashville Area: 615-255-3175

                                                          Outside the Nashville Area: 800-223-3104

Q. WhyShould I Choose A Delta Dental
   PPO Provider?                                          OurCustomer Service Representatives are
A. You can choose any dentist; however, here              available to answer your questions from 7:00
   are some reasons why it's best to choose               a.m. to 7:00 p.rn, Central time, Monday through
   a Delta Dental PPO Provider:                           Thursday, and 7:00 a.m. to 5:00 p.m. Central time
                                                          on Friday.
 • In-Network Benefits-you will receive the
   maximum benefits underthis plan when you visit
   a Delta Dental PPO Provider.                          • Talk To Your Dentist

 • Claim forms will be completed and submitted by         Talk to yourdentist and ask if he or she

   the dentist at no charge to you. Non-participating     is a Delta Dental PPO Provider.

   dentists may require you to complete forms
   and/or pay a service charge.                         Q. How Do I Start Receiving Treatment?

 • Payments to participating dentists will be based     A. On or afteryour effective date of coverage, you
   on Delta Dental's maximum plan allowance.               may callyour dentist and make an appointment.
   You will only have to payyour co-insurance              If your dentist participates with us, he or she
                                                           will complete and submit a claim for you at no
   amounts-meaning that you are not responsible
                                                           charge. If you go to a non-participating dentist,
   for charges that exceed the maximum plan
                                                           you may have to submit your claim to:
   allowance. There is no deductiblewhen you
                                                             Delta Dental ofTennessee

   visit a Delta Dental PPO Provider.
                                                             240 Venture Circle

 • Because Delta Dental reimburses its dentists              Nashville, TN 37228

   directly, Delta Dental PPO Providers have agreed
   to charge no more than your co-insurance             Q. How Do I Pre-Determine My Benefits?
   You don't have to paythe whole bill and wait
                                                        A. If you're considering dentalwork that will cost
   for reimbursement.
                                                           you more than $300, askyour dentist to request
 • If a non-pa rticipating dentist's fees exceed the
      a pre-determination before starting treatment.
   Maximum Plan Allowance, you are required to
            This will let you know approximately how much
   pay the difference plus your deductible and/or
         the workwill costand what your share of the
   co-insurance. You may also have to paythe entire        costs will be. Please notethat pre-determinations
   bill in advance and wait for reimbursement.             are not required and not a guarantee of benefits.

Q.Where Do I Get Answers To Questions                   Q. What is Balance Billing?
  About Providers orClaims?                             A. IfyoLl visit a dentist who is not a Delta Dental PPO
A. There are many ways to find answers to your             Provider, you will be responsible for any charges
   questions about providers and claims.                   above the maximum plan allowance in addition
 • Visitourwebsite at                                      to your deductible and/or co-insurance. A Delta to:                       Dental PPO Provider has agreed to accept the
                                                           maximum plan allowance as full payment and
    • Find out if your current dentist

                                                           may not bill you for any charges overthe
      is a Delta Dental PPO Provider

                                                           maximum plan allowance.

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