Flexible Spending‐ You may not elect this if enrolled in the HDHP. Flexible Spending Accounts must be re‐elected every year or your FSA account will
be termed December 31st. Complete enrollment form and submit to HR ‐ http://hr.richmond.edu/forms/fsa‐enrollment‐form.pdf
Medical Flexible Spending‐ ($2,700 household maximum)
Enroll
Annual amount: _____________
Decline
Dependent Care Flexible Spending‐ ($5,000 household maximum)
Enroll
Annual amount: _____________
Decline
Voluntary Life Insurance‐
Complete enrollment form and
submit to HR
http://hr.richmond.edu/benefits/common/insurance-applicat
ion.pdf
Applicant Decline
Enroll‐ Requested
Amount
Guaranteed Coverage Amount (only available
during
new hire enrollment. Requests above
these amounts
requires Life Insurance
application)
Max Coverage‐ requires health statement to be
completed
Employee
Number of
$10,000 units _____
$10,000 units ______
The lesser of 2 X’s your salary or $200,000 The lesser of 5 X’s your salary or $500,000
Spouse‐ up to
age 70
Number of
$10,000 units ______
$30,000 $50,000
Child(ren)‐ 14
days to age 26
Number of
$2,000 units ______
$10,000
Legal Resources‐ (NEW HIRES ONLY) Enroll at www.legalresources.com/enroll_now
Company ID: 264
Password:
nhlegal
Decline
Beneficiary Designation
Basic Life Insurance – Policy No. FLX960295 (If needed, list additional beneficiaries on attached page)
Employee’s Primary
Beneficiary(ies):
Relationship to Employee Social Security Number Date of Birth % (total must equal 100)
Employee’s Contingent
Beneficiary(ies):
Relationship to Employee Social Security Number Date of Birth % (total must equal 100)
Voluntary Term Life Insurance– Policy No. FLX960295 (If needed, list additional beneficiaries on attached page)
Employee’s Primary
Beneficiary(ies):
Relationship to Employee Social Security Number Date of Birth % (total must equal 100)
Employee’s Contingent
Beneficiary(ies):
Relationship to Employee Social Security Number Date of Birth % (total must equal 100)
Guidelines for Designation of Beneficiaries
Primary and Contingent Beneficiaries‐ Unless you designate a percentage, proceeds are paid to the
primary surviving beneficiaries
in equal shares. Proceeds are paid to contingent beneficiaries only when
there are no surviving primary beneficiaries. If you designate contingent beneficiaries and do not designate percentages, proceeds are paid to the surviving contingent beneficiaries in equal shares. Unless
otherwise provided, the share of a beneficiary who dies before the insured will be divided proportionately among the surviving beneficiaries in the respective category (primary or contingent).
General‐ Please be sure to include the beneficiary’s full name, social security number and relationship to you. Providing this information can help expedite the claim process by making it easier to locate and
verify beneficiaries.
Trust as Beneficiary‐ You may designate a trust as a beneficiary, using the following form: “To [name of trustee], trustee of the [name of trust], under trust agreement dates [date of trust].” If you wish to
designate a testamentary trust as a beneficiary (i.e., one created by will), you should recognize the possibility that your will which was intended to create this trust may not be admitted to probate (because it is
lost, contested, or superseded by a later will). Claim payment delays can result if the beneficiary designation doesn’t provide for this situation.
By completing this form you attest that your covered dependents are eligible dependents under the University of Richmond Employee Welfare Benefits Plan, or that you
do not wish to cover dependents under the plan at this time. You understand that the University may require you to provide documentation to prove your dependents are
indeed eligible for benefits, and you agree to provide such documentation upon request. You understand that your provision of dependent information is the basis on
which dependent coverage will be provided under the plan. You acknowledge that you will notify the plan administrator of any changes to your dependent information
within 31 days of the change. Any misstatement, omission or fraud by you may result in future claims being denied, your coverage and/or your dependents’ coverage
being prospectively terminated without notice and/or retroactively terminated upon 31 days’ notice, and/or your submission to disciplinary action. You, and any person
authorized to act on your behalf, are entitled to receive a copy of this form upon the appropriate request.
______________________________________________________
Employee Signature
_______________
Date
Voluntary Accident Insurance
Applicant
Enroll
Employee
Emp
loyee/Child(ren)
Decline
Employee/spouse
Employee/
Family
Voluntary Hosp
ital Insurance
Applicant
Enroll
Decline
Employee
Emp
loyee/Child(ren)
Employee/spouse
Employee/
Family
2
