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					                                      CITY OF SAN ANTONIO
                                     2006 Benefits Enrollment Form
                                       Non-Uniformed Employee
Name:___________________________________                                     In case of emergency contact:

Address:_________________________________                          Name:___________________________________
                                                                   Phone: __________________________________
City:_____________________________________                         Relationship: ____________________________

State:_____________________ Zip: __________

Home Phone:_______________________                       Social Security Number:_________________________

Work Phone:________________________                      Date of Birth:___________ Hire Date:______________

Section 1. Complete the following Categories. If one of the following is chosen: CitiMed HMO,
Delta Dental, TriCare Supplemental and / or Additonal Life Insurance, please complete and attach
an enrollment form.
Marital Status
□   Single         □   Married        □   Divorce

CitiMed PPO
□   None                     □   EE Only        □   EE + Child(ren)          □   EE + Spouse           □ EE + Family
CitiMed HMO
□   None                     □   EE Only        □   EE + Child(ren)          □   EE + Spouse           □   EE + Family

Waiver of Medical Coverage
□   No             □Yes
TriCare Supplement
□   None                     □   EE Only        □   EE + Child(ren)          □   EE + Spouse           □   EE + Family

CitiDent
□   None                     □   Employee Only           □   Employee+1              □   Employee+2

Delta Care DHMO
□   None                     □   Employee Only           □   Employee+1              □   Employee+2

Spectera Vision
□   None                     □   Employee Only           □   Employee+1              □   Employee+2

Aetna Additional Life Insurance*
□   None           □ Aetna Add’l Life X 1                □   Aetna Add’l Life X 2              □   Aenta Add’l Life X 3
*Additional Life Insurance is dependent upon evidence of insurability.

COSA Additional Long Term Disability
□   No             □   Yes

Reimbursement Accounts (Bi-Weekly Contributions)
□   None                     □   Health Care                       □     Dependent Care
                             $____________                         $______________
Section 2. List any dependents that need to be added to or dropped from the plan. If changes are
being made to the HMO Plan and / or the Delta Dental Plan, please complete and attach an updated
Change Form.

  Relation Codes:     “1” For Spouse            “2” For Dependent Daughter                  “3” For Dependent Son



                      Name               Birth Date       Relation              Social Security          Add/Drop
                                                           Code                   Number                  (A or D)

    1. _________________________ _________                 _______           __________________             ________

    2. ________________________            _________       _______           __________________             ________

    3. _________________________ _________                 _______           __________________             ________

    4. ________________________            _________       _______           __________________             ________

    5. _________________________ _________                 _______           __________________             ________

    6. ________________________            _________       _______           __________________             ________

    7. _________________________ _________                 _______           __________________             ________

    8. ________________________            _________       _______           __________________             ________

    9. ________________________            _________       _______           __________________             ________




Section 3. If spouse is employed by the City of San Antonio or any other employer, please provide the
name of the employer and the telephone number below.


    Spouse’s
    Employer: ______________________________________ Telephone Number: _____________________

Section 4. Read carefully, sign, date and return the form to your department’s Benefits Coordinator,
Human Resources Specialist or Employee Benefits Division if not enrolling online.

I have read the enrollment booklet explaining the City of San Antonio Benefits Program. I hereby make my election of benefits
for 2006 and understand that my election cannot be changed once this form is received by the Employee Benefits Division. I
further understand that I can only make changes in dependent coverage (i.e. newborn, adoption, marriage, divorce, etc.) with
legal documentation. This change(s) can only be done in person at the Employee Benefits Division and only within 31 calendar
days of a change in family status. I authorize payroll deductions that may result from my elections.


Check box:           □ I have made changes for 2006.
                     □ I have not made changes for 2006.

Employee Signature: _____________________________________                            Date: ___________________

				
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