keep this notice for your records. - Archdiocese of Cincinnati

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Archdiocesan Health Care Plan TYPE OF COVERAGE EMPLOYEE SPOUSE CHILD EFFECTIVE DATE Yes No Yes No Yes No ANTHEM BLUE ACCESS (PPO) LIFE LONG-TERM DISABILITY VOLUNTARY LIFE VOLUNTARY DENTAL � CHANGE LOCATION TRANSFER: ADD DEPENDENT(S) FROM: TO: CHANGE BENEFICIARY DATE OF ADDITION: FULL TIME STUDENT ADOPTION (Attach Legal Document) PART TIME TO FULL TIME LEGAL GUARDIAN (Attach Legal Document) NAME CHANGE: RETIREE 65 AND OVER, SUPPLEMENTAL MARRIAGE FROM: TO: SPOUSE/DEPENDENT UNDER OWN SSN NEWBORN OTHER (Specify:) ADDRESS CHANGE (list above) I and the Archdiocese of Cincinnati agree that my pay will be reduced by the amount of my required contribution for the benefit options I have elected under the Cafeteria Plan, and continuing for each succeeding pay period until this agreement is amended or terminated. The amount of my required contribution for the medical and/or dental benefit options selected have been separately communicated to me by Archdiocese of Cincinnati. R:\CLNTDOCS\03\GBS\20414.doc SIGNATURE DATE The Medical Benefits have been explained to me thoroughly. Unless otherwise indicated above, I DO NOT wish to enroll for medical coverage and understand that I will not be entitled to any benefits provided by the Plan. If I wish to enroll at a later date, I may be required to submit satisfactory evidence of good health at that time. SIGNATURE DATE EMPLOYER VERIFICATION: I have reviewed the application and believe to the best of my knowledge the information supplied by the insured is accurate and the insured is eligible for coverage under the plan. SIGNATURE DATE Page 2 of 10
R:\CLNTDOCS\03\GBS\20414.doc Archdiocesan Health Care Plan – Life & LTD Beneficiary Designation/Change This designation will apply to the following Standard Insurance Company coverage(s) if available to you through your Employer: Life Insurance, Life with Accidental Death & Dismemberment (AD&D). Designations made below, or on a separate sheet of paper, are not valid unless signed, dated, and delivered to the Employer during your lifetime. Sign and date the completed form and return it to your Human Resources Department. MEMBER/EMPLOYEE INFORMATION Group name Group No. BENEFICIARY INFORMATION � Your designation revokes all prior designations. � Benefits are payable to a contingent Beneficiary only if you are not survived by one or more primary Beneficiaries. � If you name two or more Beneficiaries in a class (primary or contingent), two or more surviving Beneficiaries will share equally, unless you provide for unequal shares. � If a minor (a person not of legal age) or your estate is the Beneficiary, it may be necessary to have a guardian or a legal representative appointed by the court before any death benefit can be paid. If the Beneficiary is a trust or trustee, the written trust must be identified in the Beneficiary designation. For example, “Dorothy Q. Smith, Trustee under the trust agreement dated .” � A power of attorney must grant specific authority, by the terms of the document or applicable law, to make or change a Beneficiary designation. If you have questions, consult your legal advisor. � Dependents Insurance and Supplemental Life insurance on your Spouse, if any, is payable to you, if living, or as provided under your Employer’s coverage under the Group Policy. � If you complete the “% of Benefit” box(es), the amounts should add up to 100% for each class (primary or contingent). For example, “Primary – John Q. Doe, 60%; Jane Q. Doe, 40%.” Primary – Full Name Address Soc. Sec. No. Relationship % of Benefit Contingent – Full Name Address Soc. Sec. No. Relationship % of Benefit Signature of Member/Employee Date Page 3 of 10
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keep this notice for your records. - Archdiocese of Cincinnati

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