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Your initial period of eligibility to enroll yourself and your dependents in health coverage is your first 90 days of employment. Your enrollment will become effective on the first of the month after your 90th day. Calculate your 90-day eligibility period. If you are a full-time employee and make no selection, you will be automatically enrolled in HealthSelect, $5,000 basic term life insurance and $5,000 AD&D. |
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| Please Note: Even if you waive health coverage, you may still enroll in optional coverage. |
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| Medical Coverage: |
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| New Hire health coverage will be effective the first day of the month following the 90-day wait period. Calculate this effective date. |
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|  | Waive - Check this box, if you do not want to enroll for medical coverage. | | Health Select - Check this box, if you want to enroll for Health Select. For more information about Health Select or premiums, go to benefits home page. | | HMO - Check this box, if you do want to enroll for FirstCare. For more information about FirstCare or premiums, go to benefits home page. | | HMO Name/City - Enter the city, where you want coverage. You are eligible for FirstCare if you live or work in a county where FirstCare provides service - Abilene, Amarillo, Lubbock, and Waco. | | Add/Drop Dependent - Check this box if you filling this form to add or drop dependents to your coverage. Also, please complete 'Section E.' |
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| Optional Coverage: |
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| Newly hired employees may elect coverage on First Active Duty Date or within 30 days of hire without enrolling in Medical coverage.Calculate your last date to enroll. |
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| Dental Coverage |
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| | Waive - Check this box, if you do not want to enroll for dental coverage. | | Dental Maintenance Plan - Check this box, if you want to enroll for Dental Maintenance Plan. For more information about Dental Maintenance Plan or premiums, go to benefits home page. | | Dental Choice Plan - Check this box, if you do want to enroll for Dental Choice Plan. For more information about Dental Choice Plan or premiums, go to benefits home page. | | Add/Drop Dependent - Check this box if you filling this form to add or drop dependents for their dental coverage. Also, please complete 'Section E.' |
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| Optional Life Coverage |
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| To further protect your family in the event of your death, you may purchase additional term life insurance. During your first 31 days of employment, you may enroll in term life insurance coverage at one time (OL1) or two times (OL2) your annual salary. This is the only time that you can enroll in this coverage without going through the evidence of insurability (EOI) process. You may also enroll in term life three (OL3) or four (OL4) times your annual salary. OL3 and OL4 always require EOI. Optional Term Life is limited to a maximum of $400,000. |
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| | Waive - Check this box, if you do not want to enroll for optional life coverage. | | OL1 (Election1) -
Check this box, if you want to enroll for OL1 (equal to your annual salary) For Election1's premiums click here. | | OL2 (Election2) - Check this box, if you want to enroll for OL2 (two times your annual salary) For Election2's premiums click here. | | OL3 (Election3) - Check this box, if you want to enroll for OL3 (three times your annual salary) For Election2's premiums click here. You will need to enroll inOL2 until receipt of approval. | | OL4 (Election4) - Check this box, if you want to enroll for OL4 (four times your annual salary) For Election2's premiums click here. You will need to enroll inOL2 until receipt of approval. |
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| AD/D Coverage |
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| Accidental Death and Dismemberment (AD&D) is insurance coverage for state agency and higher education employees that provides a benefit to you or your beneficiary if you suffer certain accidental injuries or an accidental death. Coverage of $5,000 of AD&D is included in the basic plan at no cost to you, but voluntary AD&D is separate coverage you may buy for you and your dependents. |
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| Voluntary accidental death and dismemberment (AD&D) insurance provides a benefit to you if you suffer certain accidental injuries or to your beneficiary in the event of your accidental death. Voluntary AD&D is extra accident insurance coverage for an additional premium. It is different from the double indemnity AD&D feature of basic term life coverage. Even after the initial period of eligibility, evidence of insurability (EOI) is not required to enroll in voluntary AD&D coverage. For more information go to benefits home page. Also visit ERS page on voluntary AD&D. |
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| Waive - Check this box, if you do not want to enroll for this coverage. | | Mbr Only - Check this box to enroll yourself for AD/D coverage. Click here for rates. | | Mbr + Fam - Check this box to enroll yourself and your family for AD/D coverage. Click here for rates. If you choose family coverage, a benefit is provided to you if your eligible dependents suffer certain accidental injuries or die as the result of an accident. In the event of a dependent’s accidental death or dismemberment, you would receive a percentage of your full coverage amount. You would receive 50% of your full coverage amount for accidental injuries or death of your spouse. Your children are covered for 5% of your full amount if you have a spouse who is eligible for coverage or 10% if you do not have a spouse who is eligible for coverage. | | Amount - Write an amount in the blank. You may apply for AD&D from $10,000 to $200,000 in increments of $5,000. Click here for rates. |
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| Dependent Life Coverage |
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| Dependent Term Life insurance is available for a small monthly fee, includes $5,000 basic term life insurance with $5,000 AD&D for each family member. Dependent term life insurance covers all of the dependents that you list in Section E. |
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| | Waive - Check this box, if you do not want to enroll in dependent coverage. | | Elect - Check this box, if you want to enroll your dependent's for life coverage. | | Add/Drop Dependent - Check this box if you are adding or dropping dependents. Also, please complete 'Section E.' |
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| Disability Coverage |
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| Disability income coverage is designed to provide you a monthly benefit after a waiting period if you become totally disabled. You may select either short-term or long-term disability income coverage, or both, during your first 31 days of employment without evidence of insurability (EOI). If you do not elect disability income coverage during that time, you may apply for coverage during Summer Enrollment or at a time when a Qualifying Life Event opens enrollment for you, but you will need to provide EOI. This coverage is only available to you, not to your dependents. |
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| You can either elect Short-term disability coverage or Long-term disability coverage or both. Depending upon your choice for both, check the appropriate check box - 'elect' or 'waive.' Click here for rates. |
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