1. Copyright Forrest T. Jones & Company, Inc. Please obtain an Enrollment Application from each employee and retiree who is now covered or wants to be covered by the District’s health plan.

2. Copyright Forrest T. Jones & Company, Inc. Employee Application/ Health Statement is available at www.ftj.com/meuhp

3. Copyright Forrest T. Jones & Company, Inc. Employee completes ONLY yellow questions. Prints the application and signs on first page Returns to Payroll

4. Copyright Forrest T. Jones & Company, Inc. Information for Spouse and child ONLY IF they are to be covered under the new plan.

5. Copyright Forrest T. Jones & Company, Inc. If any box is marked yes, please make sure the information is added below. Employee signs in blue area

6. Copyright Forrest T. Jones & Company, Inc. Please make sure Hours/Occupation and Date of Hire are completed Employee should check who is to be covered under the new plan.

7. Copyright Forrest T. Jones & Company, Inc. Only complete if EMPLOYEE is waiving coverage. Example 1: Bob (employee) is covered under his wife’s plan and will not be on the District plan. Bob should complete the waiver information. Example 2: Jane (employee) will be covered on District Plan. Jane’s husband and kids have other coverage. Jane should not complete the waiver information.

8. Copyright Forrest T. Jones & Company, Inc. Prior Health Insurance Information Complete with CURRENT CARRIER information. Leave Cancel Date blank. Other Health Insurance Information – Complete only for those family members who will be covered by the District plan AND other health insurance and / or Medicare.

9. Copyright Forrest T. Jones & Company, Inc. Employee only needs to read – She does not need to sign this page.

10. Copyright Forrest T. Jones & Company, Inc. THANK YOU FOR ALL YOU DO! Questions: Call 800-821-7303 ext 1179