BENEFITS ELECTION FORM Name:______________________________ (PLEASE PRINT) AETNA MEDICAL HSA PLAN OH HSA OAMC 16 RX2 ($2,750/$5,500): (Check appropriate box and circle coverage selection) Circle Election: Employee Only Employee/Spouse Employee/Domestic Partner $0.00 biweekly $ biweekly $ biweekly Employee/Child(ren) Employee/Family Employee/Domestic Partner/Child(ren) $ biweekly $ biweekly $  I am electing the Aetna HSA Plan (you must complete an enrollment form located here:  Please deduct $_____________ from my paycheck biweekly, for contribution into a Health Savings Account established by me with Fifth Third Bank.  If electing Domestic Partnership you must complete a form for Declaration AETNA MEDICAL PPO Plan – OH OAMC 3 RX 2 ($1,000/$2,000): (Check appropriate box and circle coverage selection) Circle Election: Employee Only Employee/Spouse Employee/Domestic Partner $29.01 biweekly $ biweekly $ biweekly Employee/Child(ren) Employee/Family Employee/Domestic Partner/Child(ren) $ $ $  I am electing the Aetna PPO Plan (you must complete an enrollment form) located here:  If electing Domestic Partnership you must complete a form for Declaration  I am waiving medical coverage (you must complete an waiver form located here: *IMPORTANT: You must complete the Unum Life form (indicated yes/no for dependent coverage). If you are enrolling in the medical, dental, or vision, you must complete an enrollment form. If you are waiving medical you need to complete the waiver form. IF you are electing Domestic Partnership, you must complete the Domestic Partnership Declaration form located here:

BENEFITS ELECTION FORM Please go to to access the required forms. All forms must be turned into HQ Human Resources via scan to or fax ( ) within one week of your hire Signature: ________________________________________ Date: ______________________ DELTA DENTAL: (Check appropriate box and circle coverage selection) Circle Election: Employee Only Employee/Family Employee/Domestic Partner/Family $0.00 biweekly $11.32 biweekly $11.59 biweekly  I am electing the Dental Plan (you must complete an enrollment form located here:  If electing Domestic Partnership you must complete a form for Declaration  I am waiving dental coverage 2 VSP VISION: (Check appropriate box and circle coverage selection) Circle Election: Employee Only Employee/Spouse Employee/Domestic Partner Employee/Child(ren) $0.00 biweekly $1.37 biweekly $1.43 biweekly $1.40 biweekly Employee/Family Employee/Domestic Partner/Children $2.26 biweekly$2.32 biweekly  I am electing the Vision Plan (you must complete an enrollment form located here:  If electing Domestic Partnership you must complete a form for Declaration  I am waiving vision coverage UNUM Basic Life, Long Term Disability, Short Term Disability, & Dependent Life: (Check appropriate box) You have the option to elect coverage for your dependents.  I am electing Dependent Life coverage - $1.52 biweekly (you must complete an enrollment form located here:  I am waiving Dependent Life coverage You will be enrolled in the employer-paid UNUM Life, LTD, & STD Plans. (you must complete an enrollment form located here: