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FullTime (Cisco College)

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CiscoCollege–January6,2015
Full‐Time
Faculty/Staff
NewHire
Packet
(AcademicYear2019‐20)
New Employee Information
Title:
Last Name:
First Name:
Social Security #
Address:
City,State,Zip:
Home Phone:
Cell Phone:
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
Cisco College IT Acceptable Use Policy:
Yes, I have read the Cisco College IT Acceptable
Use Policy.
Policy is available at: http://www.cisco.edu/
s/926/images/editor_documents/hr_forms/
ciscocollegepolicymanual-spring2016.pdf
Full Time Part Time
Primary Location
Cisco Abilene
FT/PT
PayCheck Disbursement:
I will pick up my check in Abilene
I will pick up my check in Cisco
I have Direct Deposit:
(please specify mail or pick up for first check)
Mail my paycheck to the following address:
__________________________________
__________________________________
__________________________________
_________________________________________________________________________________
____________________________________________________________________________________________________________
_________________________________________________________________________________
____________________________________________________________________________________________________________
(Click link above to view Policy)
Emergency Contact Person:
Relationship to Emergency Contact:
Emergency Contact Address:
Emergency Contact City, State, Zip:
________________________________________
__________________________________
_______________________________________
__________________________________
Emergency Contact Home phone: ____________________________________
Emergency Contact Work Phone: ____________________________________
Emergency Contact Cell Phone: _____________________________________
Highest Degree Earned:
Ethnicity:
Employee Classification:
Home Phone Available to Students: Yes
No
Home Email Available to Students:
Yes
No
Employee Signature: _________________________________Date: ____________________
_________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_________________________________________________________________________________
Job Title:______________________________________________________
Faculty Position:
Division:
Hire Date: _____________________________
Home Email: ___________________________________________________
____________________
__________________________
______________________________
_____________________________
______________________________
BIOGRAPHIC REPORT
NAME:______________________________________________________________________
ADDRESS:__________________________________________________________________
Street City State Zip
Telephone Number:____________________________________________________________
Social Security Number:________________________________________________________
Highest Degree or Certificate:____________________________________________________
Institution of Highest Degree:____________________________________________________
Area of Specialization:__________________________________________________________
Date of Birth:_________________________________________________________________
Total Teaching Experience:______________________________________________________
Date of Employment:___________________________________________________________
Job Title:____________________________________________________________________
Teaching Experience at Cisco College:_____________________________________________
Teaching Experience other than Cisco College:______________________________________
Ethnic origin – Please check only one:
American-Indian/Alaskan Native _______
Asian _______
Black _______
Hispanic _______
White _______
Other _______ Date:__________________
USCIS
Form I-9
OMB No. 1615-0047
Expires 08/31/2019
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 07/17/17 N
Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form.
Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which
document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ
an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name) First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
U.S. Social Security Number
-
-
Employee's E-mail Address
Employee's Telephone Number
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until
(See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1
Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
Last Name (Family Name) First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page
Form I-9 07/17/17 N
Page 2 of 3
USCIS
Form I-9
OMB No. 1615-0047
Expires 08/31/2019
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name) M.I.First Name (Given Name)
Employee Info from Section 1
Citizenship/Immigration Status
List A
Identity and Employment Authorization
Identity
Employment Authorization
OR List B AND List C
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)
First Name (Given Name) Middle Initial
B. Date of Rehire (if applicable)
Date (mm/dd/yyyy)
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative
Cisco College
101 College Heights
Cisco
TX
76437
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
6. Passport from the Federated States of
Micronesia (FSM) or the Republic of
the Marshall Islands (RMI) with Form
I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
9. Driver's license issued by a Canadian
government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
7. Employment authorization
document issued by the
Department of Homeland Security
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
4. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3
Form I-9 07/17/17 N
Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
Employer Information
1. Federal Employer ID Number (FEIN): 2. State Employer ID Number (Optional):
Please use the same FEIN that appears on quarterly wage reports.
3. Employer Name:
4. Employer Address (Please indicate the address where the Income Withholding Orders should be sent):
5. Employer City (if US): 6. State (if US): 7. ZIP Code (if US):
_
8. Province/Region (if foreign): 9. Country (if foreign): 10. Postal Code (if foreign):
11. Employer Telephone (Optional): 12. Employer FAX (Optional):
13. New Hire Contact Person (Optional):
Employee Information
14. Social Security Number (SSN): 15. Date of Hire (MM/DD/YYYY):
16. Employee First Name:
17. Employee Middle Name:
18. Employee Last Name:
19. Employee Home Address:
20. Employee City (if US): 21. State (if US): 22. ZIP Code (if US):
_
23. Province/Region (if foreign): 24. Country (if foreign): 25. Postal Code (if foreign):
26. State Where Employee Was Hired (Optional): 27. Employee DOB (MM/DD/YYYY) (Optional):
28. Employee’s Salary (Dollars and Cents) (Optional):
29. Salary Frequency (Check One ONLY) (Optional):
Hourly
Weekly
Biweekly
Semi-Monthly
Monthly
Annually
Texas Employer New Hire Reporting Form
Submit within 20 calendar days of new employee’s
first day of work to:
ENHR Operations Center, P.O. Box 149224
Austin, TX 78714-9224
Phone: 1-800-850-6442 FAX: 1-800-732-5015
Online: www.employer.texasattorneygeneral.gov
To ensure the highest level of accuracy, please print neatly
in capital letters and avoid contact with the edges of the
boxes. The following will serve as an example:
A
B
C
1
2
3
REV 12/13 ENHR RPT FORM
7 5 1 1 6 4 3 4 3
C I S C O C O L L E G E
1 0 1 C O L L E G E
C I S C O
T X
2 5 4 4 4 2 5 1 2 1
2 5 4 4 4 2 5 1 0 0
INSTRUCTIONS FOR COMPLETING THE TEXAS EMPLOYER NEW HIRE REPORTING FORM
The purpose of the Texas New Hire Reporting Form is to allow employers to fulfill new hire reporting requirements. You may enter your
employer information and photocopy a supply and then enter employee information on the copies.
REPORTING OF NEW HIRES IS REQUIRED:
All required items (numbers 1, 3, 4, 5, 6, 7, 14, 15, 16, 17, 18, 19, 20, 21, 22) on this form must be completed.
Box 1: Federal Employer ID Number (FEIN). Provide the 9-digit employer identification number that the federal government assigns to the
employer. This is the same number used for federal tax reporting. Please use the same FEIN that appears on quarterly wage reports.
Box 2: State Employer ID Number (Optional). Identification number assigned to the employer by the Texas Workforce Commission.
Box 3: Employer Name. The employer name as listed on the employee’s W4 form. Please do not provide more than one employer name
(for example, “ABC, Inc DBA. John Doe Paint and Body Shop” is not correct).
Box 4: Employer Address. Please indicate the address where the Income Withholding Orders should be sent. Do not provide more
than one address (for example, P.O. Box 123, 1313 Mockingbird Lane is not correct).
Box 8: Employer Province/Region (if foreign). Provide this information if the employer address is not in the United States.
Box 9: Employer Country (if foreign). Provide the two letter country abbreviation if the employer address is not in the United States.
Box 10: Postal Code (if foreign). Provide the postal code if the employer address is not in the United States.
Box 13: New Hire Contact Person (Optional). Providing the name of a contact staff person will facilitate communication between the
employer and the Texas Employer New Hire Reporting Program.
Box 15: Date of Hire. List the date in month, day and year order. Use four digits for the year (for example, 2001). This should be the first
day that services are performed for wages by an individual. If you are reporting a rehire (where a new W-4 is prepared) use the return date,
not the original date of hire.
Box 23: Employee Province/Region (if foreign). Provide this information if the employee does not reside in the United States.
Box 24: Employee Country (if foreign). Provide the two letter country abbreviation if the employee address is not in the United States.
Box 25: Postal Code (if foreign). Provide the postal code if the employee address is not in the United States.
Box 26: State Where Employee was Hired. Use the abbreviation recognized by the U.S. Postal Service for the state in which the
employee was hired.
Box 27: Employee DOB (Date of Birth) (Optional). List the date in month, day and year order. Use four digits for the year (for example,
1985).
Box 28: Employee Salary (Optional). Enter employee’s exact wages in dollars and cents. This should correspond to the salary pay
frequency indicated in Box 29.
Box 29: Salary (Check One ONLY) (Optional). Check the appropriate box relating to the employee’s salary pay frequency. Check “ Bi-
weekly” if the salary is based on 26 pay periods. Check “Semi-monthly” if the salary is based on 24 pay periods. Check “Annually” if salary
payment is a one-time distribution.
SUBMISSION OF NEW HIRE REPORTS. The Texas Employer New Hire Reporting Program offers a variety of methods that employers
can use to submit new hire reports. For further information on which method may be best for you, call 1-800-850-6442. Employers are
encouraged to keep photocopies or electronic records of all reports submitted. When the form is completed, send it to the Texas Employer
New Hire Reporting Program using one of the following means:
FAX: 1-800-732-5015
U.S. Mail:
ENHR Operations Center
P.O. Box 149224
Austin, TX 78714-9224
Telephone Submissions: 1-800-850-6442
Internet Submissions: www.employer.texasattorneygeneral.gov
Employers must provide all of the required information within 20 calendar days of the employee's first day of work to be in
compliance. State law provides a penalty of $25 for each employee an employer knowingly fails to report, and a penalty of $500 for
conspiring with an employee to 1) fail to file a report or 2) submit a false or incomplete report.
REV 12/13 ENHR RPT FORM
DIRECT DEPOSIT AUTHORIZATION FORM
Name:_______________________________________________________________________
Last Name First Name MI
SSN:____________________________________
Payroll Type: Se mi-Monthy Monthly
______START: I authorize you and the financial institution listed below to deposit my
net pay automatically to my account(s) each payday, and to initiate adjustments, if
necessary, for any entries made in error to my accounts.
______CHANGE Checking and/or Savings: I authorize you to change my direct deposit
to the account(s) at the financial institution listed below.
______STOP: I authorize you to stop the direct deposit of my net paycheck.
Institution Name__________________________ ________% of net check or $___________
Account Type: _____Checking _____Savings Account Number: _______________________
Bank Routing /Transit Number: ___ ___ ___ ___ ___ ___ ___ ___ ___
Signature: _______________________________________ Date: ___________________
Shaded Area for Payroll Use Only
Received
Prenoted Deposited
A VOIDED CHECK MUST BE PROVIDED IN THE SPACE BELOW
Routing/Transit Number -
Routing/Transit is a 9
-digit
number that identifies the
financial institution where
your checking account is
located.
Account Number - This is
your checking account
number.
Check Number - The financial institution scans the
check number electronically
in order for it to appear on
your monthly statement.
DIRECT DEPOSIT INFORMATION
1. The payroll deposit authorized by the employee’ signature on the Direct Deposit
Authorization form is accomplished by a process known as electronic funds transfer. It is
covered by a number of Federal regulations designed to safeguard the integrity of the
employee’s account
2. The funds deposited should be available to the employee for withdrawal by all regular
means on the morning of the scheduled payday.
3. The electronic funds transfer system requires an additional step known as pre-
notification. This is a procedure whereby account numbers must be verified by the
receiving financial institution before we will transmit direct deposit data to them.
Therefore new authorizations, changes, or cancellations should be in the Payroll
Department one month prior to the month the authorization, change or cancellation is to
take effect. If the authorization cannot be processed, Payroll will notify the employee,
who will continue to receive a payroll check until the authorization can be processed.
4. The pre-notification process also dictates that if a change in the financial institution or
account number is made, the employee must be removed from direct deposit for a
minimum of one pay period before the change will take effect. For the payday(s) the
employee will receive a payroll check(s).
5. Cisco College assumes no responsibility to issue a payroll check to any employee whose
direct deposit could not be processed due to his/her account being closed, or any other
reason, until the receiving financial institution has either refunded or guaranteed refund
of such deposit to the College.
RETURN
COMPLETED FORM TO:
Cisco College
Human Resources Office
101 College Heights
Cisco, TX 76437
EMPLOYEE HANDBOOK
I verify that I will read the Cisco College Employee Handbook. The handbook is
located on the Cisco College Website/Intranet at:
http://csacs01/policy/default.aspx
___________________________
Signature of Employee
___________________________
Date
Statement Concerning Your Employment in a Job
Not Covered by Social Security
Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you
may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social
Security based on either your own work or the work of your husband or wife, or former husband or wife, your
pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will
not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be
affected.
Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a
modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As
a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For
example, if you are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of
this provision is $313.50. This amount is updated annually. This provision reduces, but does not totally eliminate,
your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall
Elimination Provision.”
Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you
become entitled will be offset if you also receive a Federal, State or local government pension based on work
where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or
widow(er) benefit by two-thirds of the amount of your pension.
For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security,
two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are
eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100).
Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still
eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government
Pension Offset.”
For More Information
Social Security publications and additional information, including information about exceptions to each provision,
are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard of
hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.
I certify that I have received Form SSA-1945 that contains information about the possible effects of the
Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social
Security benefits.
Signature of Employee Date
Form SSA-1945 (12-2004)
Employee Name Employee ID#
Employer Name Employer ID#
CISCO COLLEGE
Information about Social Security Form SSA-1945
Statement Concerning Your Employment in a Job Not Covered by Social Security
New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires State
and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not
covered under Social Security. The statement explains how a pension from that job could affect future Social
Security benefits to which they may become entitled.
Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the
document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential
effects of two provisions in the Social Security law for workers who also receive a pension based on their work in
a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker’s
Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social
Security benefit received as a spouse or an ex-spouse.
Employers must:
• Give the statement to the employee prior to the start of employment;
• Get the employee’s signature on the form; and
• Submit a copy of the signed form to the pension paying agency.
Social Security will not be setting any additional guidelines for the use of this form.
Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/form1945.
Paper copies can be requested by email at oplm.oswm.rqct.orders@ssa.gov or by fax at 410-965-2037. The
request must include the name, complete address and telephone number of the employer. Forms will not be sent to
a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. The
forms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.
Form SSA-1945 (12-2004)
OATH OF OFFICE
In the name and by the authority of
STATE OF TEXAS
I, ______________________________________________do solemnly swear (or affirm), that
(Employee Name)
I will faithfully execute the duties of the office of ____________________________________
(Job Title - including subject if teaching)
Of the State of Texas, and will to the best of my ability preserve, protect, and defend the
Constitution and laws of the United States and of this State; and I furthermore solemnly swear
(or affirm), that I have not directly nor indirectly paid, offered, or promised to pay, contributed,
nor promised any public office or employment, as a reward to secure my appointment or the
confirmation thereof. So help me God.
__________________________________
Signature
Sworn to and Subscribed before me this
_________day of _____________, 20___
_____________________, Notary Public
_____________________, County, Texas
THE EMPLOYEES RETIREMENT SYSTEM OF TEXAS
SUMMARY NOTICE OF PRIVACY PRACTICES
T
he Employees Retirement System of Texas (“ERS”) administers the Texas Employees Group Benefits Program,
including your health plan, pursuant to Texas law. THIS NOTICE DESCRIBES HOW ERS MAY USE OR DISCLOSE
MEDICAL INFORMATION ABOUT YOU AND HOW YOU CAN GET ACCESS TO YOUR OWN INFORMATION
PURSUANT TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (“HIPAA”)
PRIVACY RULE. PLEASE REVIEW THIS NOTICE CAREFULLY.
Uses and disclosures of health information:
ERS and/or a third-party administrator under contract with ERS may use health information about you on behalf of your
health plan to authorize treatment, to pay for treatment, and for other allowable health care purposes. Health care
providers submit claims for payment for treatment that may be covered by the group health plan. Part of payment includes
ascertaining the medical necessity of the treatment and the details of the treatment or service to determine if the group
health plan is obligated to pay. Information may be shared by paper mail, electronic mail, fax, or other methods.
B
y law, ERS may use or disclose identifiable health information about you without your authorization for several reasons,
including, subject to certain requirements, for public health purposes, for auditing purposes, for research studies, and for
emergencies. ERS provides information when otherwise required by law, such as for law enforcement in specific
circumstances. In any other situation, ERS will ask for your written authorization before using or disclosing any identifiable
health information about you. If you choose to sign an authorization to disclose information, you can later revoke that
authorization to stop any future uses and disclosures. ERS cannot use or disclose your genetic information for
underwriting purposes. ERS may change its policies at any time. When ERS makes a significant change in its policies,
ERS will change its notice and post the new notice on the ERS website at www.ers.state.tx.us. Our full notice is available
For more information about our privacy practices, contact the ERS Privacy Officer. ERS originally adopted its Notice of
Privacy Practices and HIPAA Privacy Policies and Procedures Document April 14, 2003, and subsequently revised them
effective February 17, 2010, and September 23, 2013.
Individual rights:
In most cases, you have the right to look at or get a paper or electronic copy of health information about you that ERS
uses to make decisions about you. If you request copies, we will charge you the normal copy fees that reflect the actual
costs of producing the copies including such items as labor and materials. For all authorized or by law requests made by
others, the requestor will be charged for production of medical records per ERS’ schedule of charges. You also have the
right to receive a list of instances when we have disclosed health information about you for reasons other than treatment,
payment, healthcare operations, related administrative purposes, and when you explicitly authorized it. If you believe that
information in your record is incorrect or if important information is missing, you have the right to request that ERS correct
the existing information or add the missing information. You have the right to request that ERS restrict the use and
disclosure of your health information above what is required by law. If ERS accepts your request for restricted use and
disclosure then ERS must abide by the request and may only reverse its position after you have been appropriately
notified. You have the right to request an alternative means of communications with ERS. You are not required to explain
why you want the alternative means of communication.
Complaints:
If you are concerned that ERS has violated your privacy rights, or you disagree with a decision ERS has made about
access to your records, you may contact the ERS Privacy Officer. You also may send a written complaint to the U.S.
Department of Health and Human Services. The ERS Privacy Officer can provide you with the appropriate address upon
request.
Our Legal duty:
ERS is required by law to protect the privacy of your information, provide this notice about our information practices, follow
the information practices that are described in this Notice, and obtain your acknowledgement of receipt of this Notice.
Detailed Notice of Privacy Practices:
For further details about your rights and the federal Privacy Rule, refer to the detailed statement of this Notice. You can
ask for a written copy of the detailed Notice by contacting the Office of the Privacy Officer or by visiting ERS’ web site at
www.ers.state.tx.us. If you have any questions or complaints, please contact the ERS Privacy Officer by calling (512) 867-
7711 or toll-free (877) 275-4377 or by writing to ERS Privacy Officer, The Employees Retirement System of Texas, P.O.
Box 13207, Austin, TX 78711-3207.
_____________________________________________________ __________________________________
Signature Date
1000 Red River Street
Austin, TX 78701-2698
(800) 223-8778
www.trs.texas.gov
Teacher Retirement System of Texas Page 1 of 3
Section 1 - Member Information
Social Security NumberName
Address
Street Address or Box Number City State Zip Code
Phone Number
Date of Birth
Election to Participate in Optional
Retirement Program and/or Refund
TRS28 (09-16)
To be completed if your refund will be sent to a foreign address:
AreyouaU.S.citizen?
Yes No
If you are not a U.S. citizen, are you a resident alien of the U.S.?
Yes No
If you answered no to both questions above, see page 1 of the Information Sheet for ORP Election and/or Refund
(TRS28IN) for additional information regarding required federal income tax withholding.
Section 2 – Prior Optional Retirement Program Election Information
Have you previously elected the Optional Retirement Program in lieu of TRS?
Yes No
If yes, institution name __________________________________ dates of employment ___________________
If yes, you are not eligible to elect ORP a second time.
Section 3 – Member Election
I elect to participate in the Optional Retirement Program (ORP) established under Chapter 830, Texas Government
Code, in lieu of membership in the Teacher Retirement System of Texas (TRS). I understand that by this election I will
not be eligible for membership in TRS unless I cease to be employed by an institution of higher education and become
employed by the Texas public school system other than in an institution of higher education. I further understand that by
electing ORP, I forfeit all accrued rights to benefits from TRS, if any, including benefits based on TRS service credit
accrued prior to this election. I am entitled only to a refund of my TRS accumulated contributions, if any. I understand
this election is irrevocable.
Section 4 – Refund Election (select one)
Refund
I elect to have my TRS accumulated contributions paid directly to me. I understand that 20% of
the taxable amount of my refund will be withheld for federal income taxes (provided the
amount is greater than $200.00). See page 2 of the Information Sheet for ORP Election and/or
Refund (TRS28IN) for information on tax withholding if you are not a U.S. citizen or resident
alien of the U.S.
Direct Rollover
I elect to have all or a portion of my TRS accumulated contributions rolled over into an
eligible retirement plan. I understand that TRS will provide me with an additional form if this
option is selected. A Refund Rollover Election form (TRS6A) must be completed and returned
to TRS.
No Refund
I elect to leave my accumulated contributions with TRS. I understand that I forfeit all accrued
rights to benefits based on my TRS service credit accrued prior to my election to participate in
ORP, if any, by electing ORP in lieu of TRS. I understand that I can apply for a refund at a
later date.
Be sure to include your name and Social Security Number on all 3 pages.
1000 Red River Street
Austin, TX 78701-2698
(800) 223-8778
www.trs.texas.gov
Teacher Retirement System of Texas Page 2 of 3
Election to Participate in Optional Retirement Program and/or
Refund
TRS28 (09-16)
Name Social Security Number
Section 5 – Payment Method for Portion Not Being Rolled Over
Direct
Deposit
I elect to have the portion of my refund being paid directly to me sent electronically to the
financial institution listed below.
Name of Financial Institution _______________________________________
Account Type (must select one)
Checking Savings
Bank Routing Number
Account Number _______________________________________
The following declaration MUST be completed if you are requesting direct deposit.
Will this payment be transferred or forwarded outside of the United States?
No Yes If yes, to what country? __________________________
Percentage to be transferred _________________%
Check I elect to have the portion of my refund paid directly to me sent to my mailing address as a
paper treasury warrant.
Section 6 - Member Certification and Signature
I acknowledge that I have received a copy of the Information Sheet for ORP Election and/or Refund (TRS 28IN) and the
Special Tax Notice Regarding Your Rollover Options Under TRS, and that I have 30 days from receipt of the notice to
consider my decision of whether to elect a direct rollover of my distribution of accumulated contributions. I understand
that once I have made an election to roll over my refund and TRS has issued the distribution, my rollover is irrevocable
and cannot be changed.
Signature of Member or Retiree Date
STATE OF COUNTY OF
On _________________________ , _________________________________ acknowledged this document before me
(date)
(printed name of person whose signature appears above)
a notary public.
(SEAL)
Be sure to include your name and Social Security Number on all 3 pages.
1000 Red River Street
Austin, TX 78701-2698
(800) 223-8778
www.trs.texas.gov
Teacher Retirement System of Texas Page 3 of 3
Election to Participate in Optional Retirement Program
and/or Refund
TRS28 (09-16)
Name Social Security Number
Section 7 - Employer Certification
This is to certify that the above named individual is eligible and has elected to participate in the Optional
Retirement Program in lieu of membership in the Teacher Retirement System of Texas.
Name of Institution of Higher Education _____________________________________________________
TRS Reporting Entity Number ________________
Effective Date of Election __________________
Date First Eligible to Elect ORP _________________
ORP Eligibility Notification Date _________________
Report Month/Year for Final Deposit to TRS _____________
Printed Name of Reporting Official ________________________________________________________
Title of Reporting Official ________________________________________________________________
Signature of Reporting Official ____________________________________________________________
Date __________________
1000 Red River Street
Austin, TX 78701-2698
(800) 223-8778
www.trs.texas.gov
Teacher Retirement System of Texas Page 1 of 3
Information Sheet for Optional
Retirement
TRS28IN (09-16)
Optional Retirement Program (ORP) Election
• The election of ORP in lieu of membership in the Teacher Retirement System of Texas (TRS) is
irrevocable.
• If you established membership in TRS prior to your election to participate in ORP, your membership in
TRS is terminated by your election to participate in ORP.
• All accrued rights to benefits from TRS, if any, are forfeited upon the election of ORP. This includes
any benefits associated with TRS service credit you accrued prior to your election to participate in
ORP, such as service or disability retirement benefits.
• Only one Election to Participate in Optional Retirement Program and/or Refund form (TRS 28) should
be filed with TRS for ORP election purposes, as you may elect ORP only once in lieu of participation
in TRS. However, if you elect not to withdraw your TRS accumulated contributions at the time you
elect to participate in ORP, you may submit a second TRS 28 only for purposes of requesting a
refund.
• The election to participate in ORP in lieu of membership in TRS must be made within 90 days of the
date you become eligible to participate in ORP.
Refund Election
A person who is a participant in ORP may withdraw their accumulated contributions from TRS; however, you
are not required to withdraw your accumulated contributions at the time the election is made. To apply for a
refund at a later date, you must submit a second TRS 28. Please note that your account will not accrue
interest after your election to participate in ORP.
Federal Income Tax Implications
Refunded amounts that represent tax sheltered contributions are subject to a mandatory 20 percent federal
income tax withholding unless you elect to roll over all eligible amounts to another eligible retirement plan.
The amount withheld may not be sufficient to cover your income tax liability for the refund. A 10 percent early
withdrawal penalty assessed by the Internal Revenue Service (IRS) may also be applicable. All or a portion of
your refund that is eligible for rollover may be rolled over. For more information regarding amounts in your
TRS account that are eligible for rollover and types of retirement plans that are eligible to receive rolled over
amounts, see the Special Tax Notice Regarding Your Rollover Options Under the Teacher Retirement
System of Texas.
If you are a non-U.S. citizen and a non-resident alien, TRS is required to withhold 30 percent for federal
income tax unless you qualify for benefits under a U.S. tax treaty. If so, you must notify TRS of your eligibility
for reduced withholding or exemption from withholding and provide TRS with a completed IRS Form W-8BEN
(Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding) and any other required
documentation. The W8-BEN can be obtained on the IRS’ website, www.irs.gov, or from TRS upon request.
TRS recommends that you submit the completed Form W-8BEN with your TRS 28 in order to expedite the
processing of your refund.
It is your responsibility to submit the proper tax returns to the IRS and to pay any additional taxes or penalties
that may be due. TRS encourages you to contact your professional tax advisor for specific advice on how this
distribution may affect your taxes.
1000 Red River Street
Austin, TX 78701-2698
(512) 542-6400 (800) 223-8778
www.trs.texas.gov
Teacher Retirement System of Texas Page 2 of 3
Information Sheet for Optional Retirement
TRS28IN (09-16)
Additional Information about Rollovers
If you elect either a full or partial rollover, TRS will make the treasury warrant for the rollover payable to the
trustee of the eligible retirement plan named on the Refund Rollover Election form (TRS 6A). TRS will mail
the treasury warrant for the rollover to the address listed on your TRS 28. You are responsible for
forwarding the treasury warrant to the plan receiving the rollover in order to complete the rollover.
If the amount you elect to roll over is less than the total amount in your account at the time of distribution,
TRS will pay any balance to you through a second payment, which will be payable to you and issued as
either a direct deposit or paper treasury warrant.
If the amount you elect to roll over is less than your account total, TRS will roll over your tax sheltered funds
first, then your non-tax sheltered funds to reach the total dollar amount you chose to roll over. If the amount
you wish to roll over is less than your tax sheltered amount, TRS will pay you the remaining tax sheltered
amount minus 20% for federal income tax withholding, plus any non-tax sheltered amount in your account.
Roth IRAs: A rollover to a Roth IRA results in a taxable distribution in the year in which it is paid by TRS. If
you choose to rollover to a Roth IRA, you must complete Section 3 of the TRS 6A regarding your
withholding preference. TRS recommends that you consult with a professional tax advisor about whether
the tax sheltered amount of your refund is subject to the 10% additional tax on early distributions described
in the Special Tax Notice Regarding Your Rollover Options Under the Teacher Retirement System of Texas.
Foreign Trusts: A direct rollover may be made to a foreign trust that is part of a stock bonus, pension, or
profit sharing plan established outside the U.S., if the receiving foreign trust would qualify for exemption
from tax under Internal Revenue Code (IRC) §§ 401(a) and 501(a), except for the fact that it is a trust
created or organized outside the U.S. To claim this exemption, in addition to any other information required
by TRS, the distributee must furnish a written statement by an authorized official of the foreign trust stating
that the foreign trust is a trust described under IRC § 402(d). TRS will not make a transfer to a foreign trust
without this statement.
Tax Statements Sent by TRS
Tax statements (Form 1099-R) are required to be mailed to your address on record no later than January 31
of the year following a refund. Form 1099-R includes the total amount of the lump sum distribution, any
portion that is taxable income for the year paid, and the amount of income tax withheld. This information is
also provided to the IRS as required by federal law. If you are a non-U.S. citizen and non-resident alien,
TRS will report your distribution on a Form 1042-S instead of on a Form 1099-R.
If you elect to roll over all or a part of your refund, you will receive a separate Form 1099-R regarding the
rollover amount. Tax statements are mailed to the same address used for refunds. You must notify TRS in
writing if your address changes after you receive your refund. TRS must receive your notification prior to
December 10 of the year in which you received your refund in order to ensure that the form will be sent to
the correct address.
1000 Red River Street
Austin, TX 78701-2698
(800) 223-8778
www.trs.texas.gov
Teacher Retirement System of Texas Page 3 of 3
Election to Participate in Optional Retirement Program
and/or Refund
TRS28 (09-16)
Instructions
If you are electing ORP participation and requesting a refund of your TRS accumulated contributions:
1. Read the Special Tax Notice Regarding Your Rollover Options Under The Teacher Retirement
System of Texas.
2. Complete the Election to Participate in Optional Retirement Program and/or Refund form (TRS 28) in
its entirety.
3. Section 4 – Refund Election. You must select one of the three options: Refund, Direct Rollover, or No
Refund.
4. Section 5 – Payment Method for Portion Not Being Rolled Over. You may select either Direct Deposit
or a paper treasury warrant. If you select Direct Deposit, be sure to include your financial institution
name, account type, bank routing number, account number, and complete the declaration.
5. Sign the form in the presence of a notary public in Section 6 – Member Certification and Signature.
6. Have your employer complete Section 7 – Employer Certification.
7. Send the completed form to TRS.
If you previously elected ORP participation but you did not withdraw your TRS accumulated contributions at
the time you elected ORP and you are now applying for a refund of your TRS accumulated contributions:
1. Read the Special Tax Notice Regarding Your Rollover Options Under The Teacher Retirement
System of Texas.
2. Complete Section 1 – Member Information on the Election to Participate in Optional Retirement
Program and/or Refund form (TRS 28).
3. Do Not Complete Section 2 – Prior Optional Retirement Program Election Information.
4. Do Not Complete Section 3 – Member Election.
5. Complete Section 4 – Refund Election. You must select one of the three options: Refund, Direct
Rollover, or No Refund.
6. Complete Section 5 – Payment Method for Portion Not Being Rolled Over. You may select either
Direct Deposit or Check. If you select Direct Deposit, be sure to include your financial institution name,
account type, bank routing number, account number, and complete the declaration.
7. Sign the form in the presence of a notary public in Section 6 – Member Certification and Signature.
8. Do not have your employer complete Section 7 – Employer Certification.
9. Send the completed form to TRS.
Important Information
The form must be signed in front of a notary. If your name on the TRS 28 is different than the one shown on TRS
records, you must send TRS a copy of the court order or marriage license documenting your name change. If your
attorney-in-fact signs the request, a copy of the power of attorney must be submitted for review.
Please note that in some cases, TRS will issue your refund payment as a paper treasury warrant even when you have
selected direct deposit. This may occur if the direct deposit information was not completed in its entirety. In addition, if
you elect direct deposit and indicate that 100% of the refund will be transferred out of the United States, you will not be
able to receive your refund through direct deposit and TRS will issue your refund payment as a paper treasury warrant
mailed to the address listed on your TRS 28 form.
If you would like to roll over all or a portion of your accumulated contributions that are eligible for rollover, a Refund
Rollover Election form (TRS 6A) must be submitted to our office. You must complete and sign the form TRS 6A
indicating the amount that you wish to roll over. The representative of the retirement plan (plan administrator or trustee)
accepting the rollover must also sign the form certifying that the plan is eligible to receive the funds being rolled over
from your TRS account. Refer to the Special Tax Notice Regarding Your Rollover Options Under the Teacher
Retirement System of Texas included with the Requesting a Refund packet for additional information as you consider
whether to roll over your refund.
02 2018
Cisco College
Optional Retirement/Tax Sheltered Annuities
Approved Program Carriers
Contact Information
New Accounts:
VALIC
Representative: Landon Freeman
https://www.valic.com
682-557-9384
Lincoln Financial Group
Representative: Lawrence Smith
https://www.lfg.com
www.elsvisionwealth.com
(469) 271-1318
VOYA Financial Services (formerly ING/Aetna)
Representative: Zera Harris
www.voya.com
(972) 225-1524
ISC Group, Inc.
Representative: Frank Wilson
www.iscgroup.com
(940) 781-6053 cell
NOTICE TO EMPLOYEES CONCERNING
WORKERS’ COMPENSATION IN TEXAS
COVERAGE: [Name of employer]
has workers’ compensation insurance coverage from [name of commercial insurance company]
in the event of
work-related injury or occupational disease. This coverage is effective from [effective date of workers’
compensation insurance policy] . Any injuries or occupational diseases which occur on or after
that date will be handled by [name of commercial insurance company]
. An employee or a person acting on the employee’s behalf,
must notify the employer of an injury or occupational disease not later than the 30th day after the date
on which the injury occurs or the date the employee knew or should have known of an occupational
disease, unless the Texas Department of Insurance, Division of Workers’ Compensation (Division)
determines that good cause existed for failure to provide timely notice. Your employer is required
to provide you with coverage information, in writing, when you are hired or whenever the employer
becomes, or ceases to be, covered by workers’ compensation insurance.
EMPLOYEE ASSISTANCE: The Division provides free information about how to le a workers’
compensation claim. Division staff will answer any questions you may have about workers’
compensation and process any requests for dispute resolution of a claim. You can obtain this assistance
by contacting your local Division eld ofce or by calling 1-800-252-7031. The Ofce of Injured
Employee Counsel (OIEC) also provides free assistance to injured employees and will explain your
rights and responsibilities under the Workers’ Compensation Act. You can obtain OIEC’s assistance
by contacting an OIEC customer service representative in your local Division eld ofce or by calling
1-866-EZE-OIEC (1-866-393-6432).
SAFETY VIOLATIONS HOTLINE: The Division has a 24 hour toll-free telephone number for
reporting unsafe conditions in the workplace that may violate occupational health and safety laws.
Employers are prohibited by law from suspending, terminating, or discriminating against any employee
because he or she in good faith reports an alleged occupational health or safety violation. Contact the
Division at 1-800-452-9595.
Notice 6 (01/13) TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION Rule 110.101(e)(1)
Claims Administrative Services
CISCO COLLEGE
Claims Administrative Services
O
FFICE OF INJURED EMPLOYEE COUNSEL
As an injured employee in Texas, you have the right to free assistance from the Office of Injured Employee Counsel (OIEC). OIEC is
a state agency that is responsible for assisting injured employees with their claim in the workers’ compensation system.
You can contact OIEC by calling its toll-free telephone number: 1-866-EZE-OIEC (1-866-393-6432). More information about OIEC
and its Ombudsman Program is available at the agency’s website (www.oiec.state.tx.us
).
O
MBUDSMAN PROGRAM
W
HAT IS AN OMBUDSMAN?
An Ombudsman is an employee of OIEC who can assist you if you have a dispute with your employer’s insurance carrier. An
Ombudsman’s assistance is free of charge. Each Ombudsman has a workers’ compensation adjuster's license and has completed a
comprehensive training program designed specifically to assist you with your dispute.
If you have a proceeding scheduled before the Texas Department of Insurance, Division of Workers’ Compensation, an Ombudsman
can:
• Help you prepare for the proceeding (Benefit Review Conference and/or C
o
ntested Case Hearing);
• Attend the proceeding with you and communicate on your behalf; and
• Assist you with your appeal and response to insurance carrier appeals.
28
TAC §276.5. Employer Notification of Ombudsman Program to Employees (03/10)
WORKERS’ COMPENSATION INSURANCE
I have read and understood the Workers’ Compensation
Insurance information provided with my new hire packet which
includes:
Notice to new employees
Notice to new employees concerning workers’
compensation insurance in the State of Texas
Notification of the Ombudsman Program
Employee’s Printed Name: ____________________________
Signature of Employees: ____________________________
Date Signed: ____________________________
Employer’s Representative: ___________________________
CONTINUATION COVERAGE NOTIFICATION
(COBRA)
On April 7, 1986, a federal law was enacted (Public Law 99-272, commonly called COBRA). This law requires the State of
Texas to offer employees and dependents covered under the Texas Employees Group Benefits Program (GBP) the opportunity to
temporarily extend their health and/or dental coverage at the group rates. Continuation coverage is available only when certain
qualifying events cause coverage under the GBP to end. Coverage under COBRA is limited to the health and/or dental coverage in
effect at the time of the qualifying event.
Note: If eligible for optional coverages as a retiree, this document is only applicable to health.
WHO MAY CONTINUE COVERAGE
If you are an employee covered under the GBP, you and/or your covered dependents have the right to elect up to 18 months of
continuation coverage if your GBP coverage ended due to:
Termination of employment for reasons other than gross misconduct (including retirement with less than 10 years of service
credit with the Employees Retirement System of Texas (ERS), Teacher Retirement System (TRS) of Texas or an Optional
Retirement Program (ORP)
Loss of GBP eligibility due to expiration of coverage following leave without pay
Loss of GBP eligibility due to reduction of hours
If you are a dependent covered by an employee under the GBP, you have the right to elect up to 36 months of continuation
coverage if your GBP coverage ended due to loss of dependent status, including such qualifying events as:
Death of the employee
Divorce of the employee and covered spouse
A dependent child who marries or attains age 25
An other than natural child who moves out of the employees household
If you are a former employees dependent continuing GBP coverage under COBRA as a result of the former employees termination
of employment, expiration of coverage following leave without pay or loss of GBP eligibility due to reduction of hours, you have
the right to extend your coverage for a total continuation period of up to 36 months if a secondary qualifying event occurs and you
lose dependent status under the rules of the GBP provided you were covered as a dependent at the time of the initial qualifying
event. A COBRA participants newborn child or newly adopted child acquired on or after the initial qualifying event who is added
to the existing COBRA coverage will also have a right to extend their coverage. Secondary qualifying events which occur during
the initial 18 months of continuation coverage that entitles covered dependents to the additional continuation period are:
Death of the former employee
Divorce of the former employee and covered spouse
A dependent child who marries or attains age 25
An other than natural child who moves out of the employees household
The former employee begins receiving Medicare benefits.
ELECTION PERIOD
For employees and dependents eligible for continuation coverage
The ERS will provide you with a COBRA Election Form and COBRA Notification following the termination of your coverage.
You and/or your dependents must formally elect continuation coverage on the form provided and submit the appropriate premium
payment within 105 days of the date coverage terminated or the date of notice, whichever is later. Failure to do so will result in
the forfeiture of your continuation coverage. Each covered participant has the right to elect continuation coverage independently.
You and your dependents will not have coverage after the date coverage terminated until you formally elect continuation
coverage and pay all premiums due retroactive to the first day of the month following the date coverage terminated.
For dependents whose coverage terminates due to loss of dependent status
The member or the covered dependent has the responsibility to notify one of the following of a divorce or when a covered
dependent loses dependent status. Notification must occur within 60 days of the qualifying event date.
Active employee  your agency or institution Benefits Coordinator
Retiree or current COBRA participant  the Employees Retirement System of Texas (ERS)
COB Notice (R 09/2003) Page 1 of 4
Upon notification the ERS will provide a form for the dependent to complete and forward to the ERS with the appropriate
premium within 105 days of the date of notice on the form or the date coverage terminated, whichever is later. If the Benefits
Coordinator or the ERS is not notified within 60 days, continuation coverage will be forfeited.
Adding newly acquired dependents during the election period
Newly acquired dependents may be added to the COBRA continuation coverage provided the ERS is notified in writing within 30
days of the date the individual first became an eligible dependent. This rule also applies during the 105-day election period.
Example: An employee terminated employment on July 20 and acquired an eligible dependent on August 5. To add the new
dependent to the COBRA continuation coverage, the request must be postmarked on or before September 4 even though the 30-
day notification deadline occurs before the end of the 105-day election period.
COST OF CONTINUATION COVERAGE
Persons electing continuation coverage must pay the full premium plus an additional 2% administrative fee. The first premium
payment is due within 105 days from the date of the COBRA qualifying event or the date of notice, whichever is later. If you will
receive an annuity from ERS, your monthly premium will be automatically deducted from your monthly annuity payment. To
ensure that no break in coverage occurs, the first premium payment must include all premiums due retroactive to the first day of
the month following the date coverage terminated. Subsequent monthly payments are due on the first of each coverage month
and must be postmarked by the U. S. Postal Service within 30 days of the due date. If your payment is late, your coverage will
be automatically cancelled retroactive to the last day of the month in which a full payment was received and was not considered
delinquent.
LENGTH OF CONTINUATION COVERAGE
Your continuation coverage may be cancelled for any of the following reasons:
The required premium for your continuation coverage is not received within the required time period, regardless of the
circumstances.
You enroll in another group health plan on or after the COBRA coverage effective date unless the other group health plan
subjects you to a pre-existing condition limitation or exclusion. If you enroll in another group health plan, your COBRA
coverage will end when the new group health plan covers you and does not limit or exclude coverage for pre-existing
conditions in accordance with Public Law 104-191 (Health Insurance Portability and Accountability Act of 1996).
You begin receiving Medicare benefits on or after the COBRA coverage effective date.
The GBP ceases to provide coverage to any employee/retiree.
You extend coverage due to a disability and the Social Security Administration (SSA) makes a final determination that the
disability no longer exists.
You submit a written request to cancel coverage. Cancellations will be made effective the last day of the month in which the
U. S. Postal Service postmarks your request. Therefore, you must make the full premium payment for the month in which
you are mailing the cancellation request.
IMPORTANT: Cancelled continuation coverage cannot be reinstated.
Special provision for covered individuals who are determined to be disabled by the SSA
An 18-month continuation coverage period may be extended to a possible maximum of 29 months if a qualified beneficiary is
determined to be disabled under Title II or XVI of the Social Security Act at any time prior to or during the first 60 days of COBRA
continuation coverage. The disabled individual may be any qualified beneficiary whose coverage was continued under COBRA
due to termination of employment, expiration of coverage following leave without pay or due to reduction of hours. To be eligible
for the extension, the ERS must be notified by submitting a copy of the SSA Notice of Award letter during the initial 18 months of
COBRA continuation coverage. Coverage will be extended for an additional 11 months or until Medicare entitlement begins,
whichever occurs first. The premium for the additional months of coverage will be equal to 150% of the current cost of coverage
in the GBP. A covered individual who may be eligible for the coverage extension period due to a disability must contact the local
SSA office to begin the determination process.
Conversion to an individual policy
Within thirty (30) days after the date your COBRA continuation coverage expires, you may enroll in an individual conversion health
plan and or dental plan. Please contact your health and/or dental plan for specific information.
Questions about COBRA continuation coverage should be direct to the
Customer Benefits Division of the Employees Retirement System at
(512) 867-7711 or toll free (877) 275-4377 (outside the Austin calling area only)
COB Notice (R 09/2003) Page 2 of 4
Information for Participants Continuing Their Coverage
We have prepared some of the most commonly asked questions regarding COBRA continuation coverage. These are general
questions only. For more specific information, please contact the Customer Benefits Division of the Employees Retirement
System (ERS) directly at (512) 867-7711 or toll-free (877) 275-4377 (outside the Austin calling area). Our mailing address is
P. O. Box 13207, Austin, Texas 78711-3207.
What is COBRA?
COBRA is an acronym for Consolidated Omnibus Budget Reconciliation Act of 1985. COBRA requires employers to offer
continuation of group health and/or dental benefits for a specified time to individuals who would otherwise lose coverage due to
certain qualifying events.
What is a Qualified Beneficiary?
An individual who is entitled to COBRA continuation coverage due to being covered under a group health and/or dental plan on the
day the qualifying event causes loss of coverage (e.g., termination of employment, divorce from the covered employee, etc.).
This also includes a COBRA participants newborn child or newly adopted child acquired who is added to the coverage on or after
the initial qualifying event.
How long can a Qualified Beneficiary keep COBRA coverage?
If a qualifying event is due to termination of employment, loss of coverage following leave without pay or reduction in hours, a
qualified beneficiary is entitled to a maximum of 18 months of continuation coverage. All other qualifying events entitle a qualified
beneficiary up to 36 months of coverage. An 18-month continuation period may be extended to 36 months if a secondary
qualifying event occurs during the initial 18-month continuation coverage period (e.g., divorce, death or loss of dependent status).
A qualified beneficiary is never entitled to more than 36 months of continuation coverage.
How long can a disabled individual remain on COBRA?
A qualified beneficiary who is determined to be disabled by the SSA under Title II or XVI before or at any time during the first 60
days of COBRA coverage may be eligible to extend coverage from 18 to a possible maximum of 29 months. The ERS must
receive a copy of the SSA Notice of Award letter prior to the end of the original 18-month continuation coverage period.
How much are the premiums?
Premiums for 18-month and 36-month qualifying events are calculated at 102% of the current group rate. The premium for
disability participants who extend their coverage beyond the initial 18 months of coverage will be calculated at 150% of the current
group rate. Premiums are recalculated every year; if the rates change, the new plan year premium amount will be effective
beginning September 1. You will be sent a new payment notice for the new plan year, after September 1. Premium amounts for
other levels of coverage may be obtained by contacting the ERS or visiting the ERS website at
www.ers.state.tx.us.
When are the premiums due?
The initial COBRA premium payment will be due within 105 days of the date coverage terminated or the date of notice whichever
is later. If you will receive an annuity from ERS, your monthly premium will be automatically deducted from your monthly
annuity payment. Subsequent premiums are due on the first day of the coverage month. Your monthly premium payment must
be postmarked within thirty (30) days of the due date or coverage will be automatically cancelled retroactive to the last day of the
month in which a full premium payment was received and was not considered delinquent. For example, your June premium
payment is due on June 1, and will be considered late if it is postmarked after June 30. If the June premium payment is late,
coverage would be terminated May 31.
Will the ERS notify me if a premium payment is not received?
It is the participants responsibility to determine if a premium payment is due. If your coverage is cancelled, you will be notified
at that time. Cancelled COBRA coverage may not be reinstated.
For what reasons can COBRA coverage be cancelled by the ERS?
COBRA coverage may be cancelled prior to the end of the continuation coverage expiration date if:
A timely premium payment is not received.
The GBP ceases to provide coverage to any employee/retiree.
COB Notice (R 09/2003) Page 3 of 4
The participant becomes covered under another group health and/or dental plan on or after the COBRA coverage effective
date unless the participant is subject to a pre-existing condition limitation or exclusion in the other group health plan. COBRA
coverage
will end when the new group health plan coverage begins and there is no limitation or exclusion for pre-existing conditions
in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The participant begins receiving Medicare benefits on or after the COBRA coverage effective date.
The participant extends coverage due to a disability and later begins receiving Medicare benefits or the SSA makes a final
determination that the disability no longer exists.
A written request is received from the participant requesting cancellation of coverage. Coverage cancellations will be made
effective the last day of the month in which the U. S. Postal Service postmarks the request. A full premium payment must be
submitted for the month in which a request for cancellation is submitted.
IMPORTANT: Cancelled COBRA coverage may not be reinstated
What if I become covered under another group health plan or begin receiving Medicare benefits?
You are responsible for notifying the ERS in writing when you enroll in another group health and/or dental plan or begin receiving
Medicare benefits. The right to continue COBRA coverage terminates when an individual becomes covered on or after the
COBRA effective date by another group health plan that does not limit or exclude coverage for pre-existing conditions OR if you
begin receiving Medicare benefits. Your COBRA coverage will be cancelled retroactive to the last day of the month prior to the
month in which you first became covered under the other group health and/or dental plan or began receiving Medicare benefits.
Under HIPAA, a group health plans pre-existing condition exclusion period will be reduced month for month by the individuals
preceding period of creditable coverage under another health plan. The continuous coverage period in another health plan is
considered creditable coverage provided there has been no lapse in coverage of more than 63 days. COBRA continuation
coverage may be terminated if a COBRA participant becomes covered by a new group health plan with a pre-existing condition
exclusion clause that is satisfied by the creditable coverage provision. The HIPAA rules limiting the applicability of exclusions
in most employers health plans for pre-existing conditions became effective in plan years beginning on or after July 1, 1997.
If a participant becomes covered by another group health plan that limits or excludes coverage for pre-existing conditions on or
after the COBRA effective date, COBRA coverage will not be terminated until the expiration of the pre-existing conditions exclusion
period. In order to continue COBRA coverage you will be required to provide the following items regarding the other group health
plan: documentation of the pre-existing conditions limitation provision, documentation of the effective date of coverage for each
person that is covered by the other group health plan and documentation (e.g. medical or prescription billings) indicating that
services were provided during the pre-existing period for each person that is covered by the other group health plan. COBRA
coverage will be cancelled on the last day of the month in which the pre-existing condition exclusion period expires.
What if I return to employment with a GBP participating agency or higher education institution?
If you return to employment with a GBP participating agency or higher education institution while your COBRA coverage is in
effect, your COBRA coverage will extend through the end of your rehire month. The full COBRA premium for the month during
which you became covered as an active employee or as a dependent of an active employee will be due. This will not result in a
break in coverage. However, if the full premium is not received, COBRA coverage will be retroactively cancelled and you will be
subject to the 90-day waiting period.
May I change my health and/or dental carrier or make changes to my COBRA coverage?
COBRA coverage will continue with your current health and/or dental carrier. If you are enrolled in a Health Maintenance
Organization (HMO) and move out of the service area where there is no other HMO available, you will be automatically enrolled
in HealthSelect. You may decrease your level of coverage by submitting a written request to the ERS. The decrease in coverage
will be effective the first day of the month following the postmarked date of your request. Newly acquired dependents may be
added if you notify the ERS in writing within thirty (30) days of the qualifying life event. (For example, if you were married on
July 1, to add your new spouse, your request must be postmarked on or before July 31). Other eligible dependents may be added
and eligible changes may be made during the annual Summer Enrollment Period or through the Evidence of Insurability (EOI)
process.
Can COBRA coverage be converted to an individual policy?
COBRA coverage may be converted to an individual policy if you apply for conversion within thirty (30) days after the date your
COBRA coverage expires or is cancelled, provided your premium payments are current. We will notify you forty-five (45) days
before the expiration date. Please contact your health and/or dental carrier for specific information about conversion.
COB Notice (R 09/2003) Page 4 of 4
COBRA
This is to certify that I have received a
CONTINUATION COVERAGE NOTIFICATION (COBRA) FORM.
___________________________
Signature of Employee
_________________
__________
Date
EEO Training Instructions
All Cisco College employees (full-time/part-time) are required by law to complete the Equal
Employment Opportunity Training upon initial employment and every two years thereafter. An
updated Computer Based Training (CBT) has been made available to us by the Texas Workforce
Commission. Please be prompt about completing this required training. Upon completion please
send a copy of your certificate to the HR Office
. Your EEO training completion date is tracked in your
Payroll System Record, and a copy is filed in your personnel file.
Yo
u will be reminded via email four weeks prior to your 2-year completion date so you will have
sufficient time to take the course again and submit your new Completion Certificate by the 2-year
mark from your previous training.
To Take the EEO Training
:
1. Ensure your computer has Adobe Flash loaded.
2. You may select the link below:
https://www.softchalkcloud.com/lesson/serve/XAU6OjCIblu1z5/html
OR
3. Go to the Cisco College website (www.cisco.edu).
• Select “Faculty & Staff” link
• Under “Human Resources,” select “EEO Training” link
• You will be at the Login Prompt for the EEO Training Course.
4. Login Information is as follows:
• You will be prompted to enter your work email address
• This will take you directly into the course
5. You can stop the course to go back to finish it at a later date. However, you cannot start the
course over again or change previously completed answers. The course will simply pick up at
the point you stopped.
6. When you are prompted at the end of the course to enter your “Agency Code,” you should
enter “Cisco College & Your name,” (EX: Cisco College - Pam Page). This information will be
used for your completion certificate. Select “Print Certificate.” Once printed, then select
“Finish.” HR MUST HAVE A COPY OF YOUR CERTIFICATE IN ORDER TO GIVE YOU CREDIT
FOR COMPLETING THE COURSE.
7. IMPORTANT INFO ONLY IF YOU ARE UNABLE TO PRINT A CERTIFICATE: If you are unable to print a
certificate (very rare occurrence), be sure to write down the “Completion Number,” and email it to
the HR Office. You must have the Completion Number in order to prove successful completion of the
course to request a printed certificate. HR must receive a copy of the certificate to credit you with
completion of the course.
July 2014
EEO Training Acknowledgment
I have received notification from Human Resources of the requirement to complete EEO Training as a
new employee of Cisco College. I understand that within 30 days of employment, I must complete
the training, print a certificate, and provide a copy of the completion certificate to the Human
Resources Office. I understand that I will have to re-certify this training every two years, if still
employed with Cisco College. I also understand that the link to take the course may be accessed by
me as indicated below:
• You may select the link below:
https://www.softchalkcloud.com/lesson/serve/XAU6OjCIblu1z5/html
OR
• Go to the Cisco College website (www.cisco.edu).
• Select “Faculty & Staff” link
• Under “Human Resources,” select “EEO Training” link
• You will be at the Login Prompt for the EEO Training Course.
I h
ave also been provided a copy of the EEO Training Instructions to assist me in completing the
training.
_______
_______________________________ ________________________________
Name Date
July 2014
Ackn
owledgement of Official Transcripts
Requirement
As a newly-hired employee with Cisco College, I understand that it is my responsibility to order and
have official transcripts sent directly to the following address:
Shelli Garrett
Director of Human Resources
101 College Heights
Cisco, Texas 76437
This
is a SACS requirement and necessary to maintain our credentialing. I further understand that
Human Resources office must receive and have on file official transcripts for all my degrees within 30
days of my hire date.
The
HR Office will confirm receipt of these transcripts to me via my Cisco College email address.
__________
_______________________________________ ______________________________
Signed Date
July 2014
Veteran Status
The following request for information is used for reporting purposes and to obtain
information for the Veteran Workforce Summary Report. The Veteran Workforce Summary
Report compiles and analyzes information on the hiring and employment of veterans by
Texas state agencies and institutions of higher education, including public community and
junior colleges.
___ I am not a Veteran ___ Disabled Veteran ___ I am a Veteran
Are you an orphan of a veteran, if veteran was killed while on active duty? YES NO
Are you a surviving spouse of a veteran (who has not remarried)? YES NO
Employee Signature __________________________ Date______________
The next section of pages (38-46) is your
ERS benefit selection forms. Please fill in
ONLY demographic information and hold
until you are scheduled with Human
Resources for the New Employee Orientation
to review benefit selections. If you are
covering any dependent children, please
complete a certification form for each child.
BENEFITS ELECTION FORM
Information provided to ERS is maintained for managing your benefits.
If you have questions about your information, or believe that information provided to ERS may be incorrect, please notify
your Benefits Coordinator or HHS Employee Service Center.
SECTION A: EMPLOYEE DATA (To be completed by employee.)
Social Security Number/National ID (SSN) Employee ID First Active Duty Date
Employee Name: First, MI, Last Eligibility County
Mailing Address o Check if new
City State ZIP Code Phone Number
o Home o Cell ( )
Email Address Gender Date of Birth
o M o F
Agency Name Dept ID/Agency Number Employee Class Insurance Pay Rate
Employee SSN/National ID Correction Employee Name Change or Correction Date of Birth Correction
Please provide this information, as it could affect the waiting period for your medical insurance.
• Were you covered as a dependent under the Texas Employees Group Benefits Program (GBP) at the time of your hire? o Yes o No
If yes, please provide the Social Security number of the person covering you: _________________________________________________
• Are you a University of Texas (UT) or Texas A&M University (TAMU) employee or dependent transferring to this GBP-participating agency or
institution without a break in health coverage? o Yes o No Date coverage ends ____________
If yes, please provide proof of no break in coverage to your benefits coordinator. If you are a Health and Human Services (HHS) Enterprise
employee, provide the proof to HHS Employee Service Center.
• Are you recently rehired with the same state agency within 90 days of leaving active military duty? o Yes o No
If yes, please provide your military release date: _______________.
SECTION B: ACTION (Mark appropriate choice.)
DTA o FTE to PTE/PTE to FTE OR Retiree RTW/Retiree LTW FSC o Family Status Change HIR o New Hire
LOA o Leave of Absence PHC o Post Hire Change RED o Reduction while on LOA REH o Rehire RFL o Return from Leave
SECTION C: REASON CODE (See Family Status Change reference table on page 4 before completing.)
Complete for changes during the plan year. Reason Code: _________ Event Date: ________________ (mm-dd-yyyy)
Continue to next page to complete form.
You may complete your benets election either by:
• Using your online account at www.ers.texas.gov, or
• Sending this completed form to your benets coordinator or HHS
Employee Service Center for employees at HHS Enterprise agencies
ERS GI-1.180 (R 5/2019) (Page 1 of 4)
ERS GI-1.180 (R 5/2019) (Page 2 of 4)
SECTION E: DEPENDENT PERSONAL DATA (and coverage choices.)
Dependent Tobacco-user Certification: If your dependents are enrolled in a GBP health plan, you must certify below if your dependent used
any type of tobacco product five or more times in the last three months. This includes but is not limited to cigarettes, pipes, cigars, cigarillos,
snuff or chewing tobacco products.
Dependent
Relationship*
Dependent’s Name
(First, MI, Last)
Gender
Date of Birth
(mm-dd-yyyy)
Dependent SSN
(Required for 12 months or older)
Health Dental Vision Dep. Life
Tobacco
User
o Sp o D
o S o O
o M
o F
o Yes
o No
o Yes
o No
o Yes
o No
o Yes
o No
o Yes
o No
o Sp o D
o S o O
o M
o F
o Yes
o No
o Yes
o No
o Yes
o No
o Yes
o No
o Yes
o No
o Sp o D
o S o O
o M
o F
o Yes
o No
o Yes
o No
o Yes
o No
o Yes
o No
o Y
es
o No
o Sp o D
o S o O
o M
o F
o Yes
o No
o Yes
o No
o Yes
o No
o Yes
o No
o Yes
o No
o Sp o D
o S o O
o M
o F
o Yes
o No
o Yes
o No
o Yes
o No
o Yes
o No
o Yes
o No
* Relationship Code: Sp – Spouse D or S - Natural or adopted daughter or son O – Other than natural or adopted child. Includes stepchild,
foster child, or ward child.
If you are adding a child, you must complete a Dependent Child Certification form (ERS GI 1.081) available at www.ers.texas.gov or by calling
ERS. For dependents newly enrolled in health coverage, you will be required to provide documentation to verify your dependents’ eligibility.
Did your dependent have GBP coverage under ERS through another member within the last 31 days? o Yes o No
If yes, please provide the Social Security number under which your dependent was covered: _________________________________
Is this dependent a new addition to your household because of this event? Please check one only:
o Adoption o Acquisition of other than natural child o Birth o Not newly acquired o Marriage
SSN _______________________________ Employee Name: First, MI, Last ________________________________________________
Employee Tobacco-User Certification: If you are enrolling in the GBP health plan, have you used any type of tobacco product five or more
times in the last three months? This includes but is not limited to cigarettes, pipes, cigars, cigarillos, snuff or chewing tobacco products.
o Yes o No
SECTION D: BENEFITS OPTIONS (Mark appropriate choices.)
Health Coverage
Optional Benets (Newly hired employees may elect benets on rst active duty date or
within 31 days of hire/rehire without enrolling in health coverage.)
Effective date, if different from hire/rehire date ______________________ (mm-dd-yyyy)
Health Dental* Vision
Optional Term Life
Insurance**
Voluntary
AD&D*
Dependent Term
Life Insurance**
Short-term
Disability**
o Waive
o HealthSelect of Texas
®
o Consumer Directed
HealthSelect
SM
o HMO Name
_____________________
o Enroll/Add/Drop
Dependent
(See Section E)
o Waive + Opt-Out Credit*
(By checking Waive + Opt
Out Credit, you also certify
that you have comparable
coverage. See page 3 for
important information.)
o Waive
o State of Texas
Dental Choice
Plan
SM
o DeltaCare USA
DHMO
o Enroll/Add/Drop
Dependent
(See Section E)
o
Waive
o State of Texas
Vision
o Enroll/
Add/Drop
Dependent
(See Section E)
o Waive
o Enroll
Elect coverage level
o OL1 Election 1
o OL2 Election 2
o OL3 Election 3
o OL4 Election 4
Decrease Level to
o OL1 Election 1
o OL2 Election 2
o OL3 Election 3
o
Waive
o You Only
o You + Family
$__________
Amount up to
$200,000 in
increments of
$5,000
o Waive
o Enroll/Add/
Drop Dependent
(See Section E)
o Waive
o Enroll
Long-term
Disability**
o Waive
o Enroll
If you want to elect a TexFlex health, dependent care, or limited account as a new enrollee or due to a
qualifying life event, you must complete the TexFlex Enrollment Change Form.
*A monthly credit of up to $60 (or $30 for part-time participants) can be applied to optional coverage (dental, vision and AD&D).
**To add this coverage will require evidence of insurability (EOI). Initiate the EOI process online by signing into your online account at
www.ers.texas.gov, or contact your benefits coordinator/HHS Employee Service Center.
Continue to next page to complete form.
ERS GI-1.180 (R 5/2019) (Page 3 of 4)
SECTION F: AUTHORIZATION (Carefully read the statements below before you sign and date.)
I authorize payroll deductions for the elections indicated on this Benefits Election Form. I understand that my insurance coverage may
be cancelled if I do not pay the required amounts due, either by payroll deduction or personal payment. I understand that all insurance
premiums are deducted on a pre-tax basis, except Dependent Life, State of Texas Dental Discount Plan, and Disability. I authorize any
provider to release any information on persons covered when needed to verify eligibility or to process an insurance claim/complaint. I
understand that insurance participation rules and enrollment and benefits information are available from my benefits coordinator/HHS
Employee Service Center or ERS. I understand that double coverage for dependents is not allowed for health, vision and dental
coverage in the Texas Employees Group Benefits Program (GBP). I understand that state law does not permit me to receive more
than one state insurance contribution as either an employee, retiree, or dependent. I certify that I am familiar with the requirements
for enrolling myself and/or dependent(s) in the GBP based on a new/post hire change or a qualifying life event (QLE). I further certify that
my QLE is valid, correct, and allowable under the GBP. I understand that I may be asked to show documentation to support my QLE and
will be required to submit documentation for any newly enrolled dependents, proving their eligibility. I also understand that if I knowingly
provide any materially incorrect, incomplete, untrue, information, I may be permanently expelled from the GBP and/or subject to criminal
prosecution.
Notice about Insurance: Funding for health and other insurance benefits for participants in the GBP is subject to change based on
available state funding. The Texas Legislature determines the level of funding for such benefits and has no continuing obligation to provide
funding for those benefits beyond each fiscal year.
Tobacco-User Certification: I certify my understanding and agreement to the following: “Tobacco Products” are cigarettes, cigars, pipe
tobacco, chewing tobacco, snuff, dip or any other products that contain tobacco, and a “Tobacco User” is a person who has used any
Tobacco Products five or more times within the past three consecutive months. If I (or any of my covered dependents): 1) have used
Tobacco Products as a Tobacco User; or 2) start using Tobacco Products without notifying ERS, I will be subject to monetary penalties
and may be terminated from participation in the GBP. Also, failure to notify ERS will constitute fraud. Under the penalties of perjury,
the above information is true and correct. Providing or entering false information may disqualify me from continued coverage in the
GBP. If I intentionally misrepresent material facts or engage in fraud, my coverage may be rescinded retroactively to the date of the
misrepresentation or fraudulent act. In that event, I will receive thirty days notice before my coverage is rescinded. Further, if I or any of my
covered dependents start using Tobacco Products without notifying ERS, I will be subject to monetary penalties and such failure to notify
ERS will constitute fraud.
If you certified yourself or any of your dependents as a tobacco user, you may be able to participate in Choose to Quit, an alternative to the
tobacco-user premium, if it is right for your health status and complies with your doctor’s recommendations. For more information about this
program, visit, https://ers.texas.gov/Tobacco-Policy-and-Certification.
If you previously certified yourself or any of your dependents as a tobacco user, and you or they have stopped using tobacco for three
consecutive months, you must complete the Tobacco-User Certification Form (ERS 2.933) available at https://ers.texas.gov/PDFs/Forms/
Tobacco_User_Certification_ERS2933.pdf, or change the certification using your online account at www.ers.texas.gov.
If you selected “Waive + Opt-Out Credit”: I certify that I do not want the health plan coverage offered to me as an eligible participant. I
am waiving my health plan coverage and certify that I have other health plan coverage with substantially equivalent coverage to the basic
health plan. I understand waiving my state health insurance will cancel my prescription drug coverage and $5,000 Basic Term Life policy.
I will receive a credit of up to $60 (or $30 for part-time participants) that will be applied only toward the cost of eligible optional coverage
in which I am enrolled (dental, vision and/or Voluntary Accidental Death and Dismemberment (AD&D) excludes the State of Texas Dental
Discount Plan). The credit is in place of the state contribution for basic health coverage. Due to federal legislation Medicare members
cannot receive the Opt-Out Credit. I am able to view the Health Insurance Opt-Out Credit applied toward my eligible optional coverage
premium by signing into my online account at www.ers.texas.gov.
I understand that if I am currently in a waived status, I must have a QLE or wait until Summer Enrollment to enroll in medical or
optional coverage offered to eligible participants.
Employee’s Signature ______________________________________________ Date Signed (mm-dd-yyyy) _____________________
Keep a copy of this form for your files and return the original to your benefits coordinator.
If you are a Health and Human Services (HHS) Enterprise employee, return this form to HHS Employee Service Center.
ERS GI-1.180 (R 5/2019) (Page 4 of 4)
New Employees:
• May elect health coverage at time of hire; however, this coverage
will be effective when you have satisfied your waiting period.
Employees making changes to their benets options during the
plan year:
• Use this form to indicate only the changes you want to make.
• Complete this form on or within 31 days after your qualifying life
event (QLE) (birth, marriage, etc.).
• Using the chart below, identify a reason code (required in Section
C) when changing insurance coverage.
Below are examples of qualifying life events; other similar
circumstances may also represent a qualifying life event. Remember,
rules will determine if you can enroll in or make the insurance
changes you want. You may either enter your changes using your
online account at www.ers.texas.gov or send this form to your
benefits coordinator.
If you are a Health and Human Services Enterprise employee, you
may send this form to HHS Employee Service Center. If you do not
make changes within 31 days, you may not be eligible to make the
changes you want.
Family Status Change Reference Chart
Employee Marital Status Change
Participant gets married MAR
Participant gets a divorce or an annulment DIV
Death of a spouse DOD
Dependent Status Change
Birth of a newborn child BIR
Participant adopts, fosters, or gets court-appointed guardianship,
or becomes managing conservator of a child
ADP
Participant gains or loses dependent(s) through death DOD
Dependent becomes eligible or loses eligibility for insurance coverage
(Example: Participant’s spouse is covering their child. The child lost eligibility for
the spouse’s insurance because the child does not attend school.)
DEP
Dependent is related by blood or marriage, and was previously claimed on the participant’s income tax
return, but is no longer eligible to be claimed on participants income tax return
XMO
Child gets married DGM
Employment Status Change
Participant/Dependent employment status change ESC
Dependent becomes eligible for insurance after a waiting period DWP
Address Change that Changes
Dependent Eligibility
Dependent moves out of health or dental plan service area DMV
Medicare/Medicaid/CHIP
Eligibility Change
Participant/Dependent gains Medicare/Medicaid/CHIP eligibility MDG*
Participant/Dependent loses Medicare/Medicaid/CHIP eligibility MDL*
Signicant Change in Cost/Coverage
Imposed byThird Party
Significant change in cost by day care provider SCC
Significant change in cost/coverage of dependent’s health, vision or dental plan (excluding GBP) SCC
HIPP approval or loss of eligibility SCC
Ofce of the Attorney General (OAG)
Ordered Coverage Change
(Eligibility rules apply for
these dependents)
Participant gains requirement to provide coverage for child through a National Medical Support Notice
(NMSN) issued by the Office of the Attorney General (OAG)
(Example: employee receives an NMSN to provide health coverage for his child.)
MSO
NMSN issued by the Office of the Attorney General (OAG), which requires
participant to provide coverage for child expires
(Example: employee’s NMSN to provide health coverage for his child expires and the employee is no longer
required to continue coverage for the child.)
MSD**
* DEPENDENT ENROLLMENT INFORMATION:
CHIPRA requires a 60-day QLE window to notify ERS if:
1. The dependent is not in the GBP and loses their eligibility for Medicaid or CHIP OR
2. The dependent is not in the GBP and they become eligible for premium assistance through Medicaid or HIPP,
they have 60 days to enroll in the GBP.
DROP DEPENDENT COVERAGE INFORMATION:
In other QLE instances related to Medicaid or CHIP there is the usual 30-day window to drop dependents from the GBP.
** Employees must contact their benefits coordinator (HHS Enterprise employees contact HHS Employee Service Center) to drop dependent(s)
added with a National Medical Support Notice (NMSN).
You may be asked to show proof of the QLE and will be required to submit documentation
for newly enrolled dependents, proving their eligibility.
Employees Retirement System of Texas PO Box 13207 Austin, Texas 78711-3207 (877) 275-4377 (TTY:711)
Pick one true statement to certify dependent eligibility:
___ 1. I certify this child is my:
(check one, a. through f.)
___ a. natural child,
___ b. adopted child,
___ c. foster child,
___ d. stepchild,
___ e. court-appointed ward, or
___ f. child under managing conservator.
- OR -
___ 2. I certify:
• this child is related to me by blood or
marriage AND
• was claimed as a dependent on my
federal income tax return in the previous
calendar year AND
• I will continue to claim this child on my
federal income tax return for every year
the child is enrolled.
- OR -
___ 3. I certify:
• this child is related to me by blood or marriage and was
not claimed on my federal income tax return for last
year because the child was born in the current calendar
year AND
• will be claimed on my federal income tax this year and
for every year the child is enrolled.
- OR -
___ 4. I certify this child is related to me by blood or marriage and is
eligible for benets in the Texas Employees Group Benets
Program due to good cause and I have read and understand
the denition of good cause provided below. Denition of
Good Cause: Good cause means that you cannot certify
this child under items 2 or 3 above because of unexpected
circumstances that required you to take parental responsibility
for the child this year. You may not certify the child for good
cause unless you will legally claim the child as your dependent
for federal income tax purposes in this current year.
ERS GI-1.081 (R 1/2018)
DEPENDENT CHILD CERTIFICATION
Information provided to the Employees Retirement System of Texas (ERS) is
maintained for managing your benets.
If you have questions about your information, or believe that
information provided to ERS may be incorrect, please notify ERS.
Complete a separate form for each dependent child to be covered.
Note: If you certify online, you do not need to complete this
form, unless requested due to a dependent eligibility audit.
You may certify your dependent either by:
• Using your online account at www.ers.texas.gov, or
• Active employees: may send this completed form to your
benets coordinator or HHS Employee Service Center, or
• Other members: may send this completed form to:
Employees Retirement System of Texas
Customer Benets
P.O. Box 13207
Austin, TX 78711-3207
(866) 399-6908 Toll-free
SECTION A: PERSONAL DATA
Employee/Retiree Name: First, MI, Last Social Security Number (SSN) Employee ID
Agency Name Dept ID/Agency Number
Legal Name of Child: First, MI, Last
Child’s Social Security Number
(Required for 12 months or older)
Child’s Birth Date
mm/dd/yyyy
SECTION B: DEPENDENT CHILD CATEGORY
SECTION C: CERTIFICATION
I understand I may be asked to show documentation to support my selection. False information could lead to expulsion from the
Texas Employees Group Benets Program and/or criminal prosecution.
_______________________________________________ _________________________
Signature of Employee/Retiree Date Signed (mm-dd-yyyy)
Member Comment – Only complete this box if you choose Option 4.
TEXAS EMPLOYEES GROUP BENEFITS PROGRAM (GBP)
SUPPLEMENTAL INFORMATION FORM FOR EMPLOYEES
Information provided to Employees Retirement System of Texas (ERS)
is maintained for managing your benets.
Please mail the completed form to your health plan carrier.
SIGN, DATE AND MAIL THIS FORM TO YOUR HEALTH PLAN.
ERS GI-1.207 (R 7/2017) Over
SECTION D: PRIMARY CARE PHYSICIAN SELECTION (for HealthSelect
SM
of Texas and Community First participants)
Name of your Health Plan:
If you’re in HealthSelect of Texas or Community First Health Plans, select your primary care physician (PCP) from the plan’s provider
directory. Attach an additional sheet if necessary.
Patient’s Name:
First, MI, Last
Social Security
Number (SSN)
Gender
Birthdate
(mm-dd-yyyy)
PCP Name:
First, MI, Last
PCP Address
NPI or
PCP No.
Existing
Patient?
Employee
o M
o F
o Yes
o No
Spouse
o M
o F
o Yes
o No
Child
o M
o F
o Yes
o No
Child
o M
o F
o Yes
o No
Child
o M
o F
o Yes
o No
Child
o M
o F
o Yes
o No
SECTION A: EMPLOYEE DATA
New Employee?
o
Yes o No
Employee Name: First, MI, Last
Birthdate
(mm-dd-yyyy)
Last four digits of
Social Security Number
Phone Number
o Home o Cell
XXX-XX-
Mailing Address City State ZIP Code Eligibility County
SECTION B: OTHER INSURANCE DATA
Please check type
of coverage:
o Employer Group Health o Employer Group Dental o Individual Health o Individual Dental
Name of Policyholder ID number
Birthdate
(mm-dd-yyyy)
Gender Relationship
o M o F o Self o Spouse o Child
Name and Address of Other
Insurance Company, TPA, HMO
Group or Policy
Effective Date _____/_____/_____
Will Coverage Continue
o Yes o No
If No, Expected Cancel Date
____/____/_____
Level of Coverage
o You Only
o You/Spouse
o You/Child(ren)
o You/Family
SECTION C: MEDICARE COVERAGE INFORMATION
Name of Medicare Beneciary Medicare Part A (Hospital) Effective Date
_____/_____/_____
Medicare Part B (Medical) Effective Date
_____/_____/_____
Medicare No. (From Medicare Card)
GENERAL INSTRUCTIONS
This GBP Supplemental Information Form is NOT an enrollment form. Enrollment forms are submitted to ERS and coverage is reported to
the selected health plan. This form will facilitate the receipt of your health care identication card once your enrollment form has successfully
been processed by ERS and your coverage reported to the selected health plan.
This GBP Supplemental Information Form must be completed, signed and dated by you when:
1) enrolling in any GBP health plan, 2) adding a dependent to your current health coverage, or 3) making an eligible health plan change (for
example, at Summer Enrollment).
SECTION A: EMPLOYEE DATA
Complete this section and specify your mailing address, ZIP Code, and Eligibility County. Indicate if you are a new employee.
SECTION B: OTHER INSURANCE DATA
Complete this section if you or any member of your family are covered by other health or dental coverage. If more space is needed, please
attach a separate sheet.
SECTION C: MEDICARE COVERAGE INFORMATION
Complete this section if you or any member of your family are covered under Medicare Part A
and/or Part B. If more space is needed, please
attach a separate sheet.
SECTION D: PRIMARY CARE PHYSICIAN SELECTION
Complete this section if you are enrolling in a GBP health plan requiring a PCP selection prior to receiving services. Refer to the provider
directories at www.ers.texas.gov when completing this section.
1. Write the name of your chosen health plan.
2. Write the full name and provider code of your chosen PCP for yourself and each covered dependent, even if you are selecting the same
physician for all covered persons.
3. Indicate if you are an existing patient or not (Y/N).
If you need assistance in completing this section, contact your health plan.
SECTION E: OTHER DEPENDENT INFORMATION
1. Complete this section if you are enrolling in HealthSelect (In-Area) and your eligible dependent lives out-of-area or in another
HealthSelect network area.
2. Complete this section if you are enrolling in an HMO and your eligible dependent lives in another Texas service area of the selected HMO.
HEALTH PLAN ADDRESSES AND TELEPHONE NUMBERS:
HealthSelect
SM
of Texas
BlueCross BlueShield
(800) 252-8039
Mail Supplemental
Information Forms to:
4002 Loop 322
Abilene, TX 79602-7330
HMO:
Community First
Health Plans, Inc.
(877) 698-7032
(210) 358-6262
Mail Supplemental
Information Forms to:
Community First
12238 Silicon Drive,
Suite 100
San Antonio, TX 78249
Scott & White
Health Plan
1206 West Campus Drive
Temple, TX 76508
Temple: (800) 321-7947
Georgetown: (800) 758-3012
Waco (254) 756-8000
KelseyCare powered by
Community Health Choice
2636 South Loop West,
Suite 900
Houston, TX 77054
(713) 295-6792;
toll-free (844) 515-4877
ERS GI-1.207 (R 7/2017) [Back]
SECTION E: OTHER COVERED DEPENDENT NOT LIVING IN THE HOUSEHOLD
o Dependent Lives Out-of-Area
o Dependent Lives in Different
Network or Service Area
Dependent Name: First, MI, Last
Social Security Number
(SSN)
Birthdate
(mm-dd-yyyy)
Mailing Address City State ZIP Code County
__________________________________________________________ _______________________________
Participant’s Signature Date Signed (mm-dd-yyyy)
EMPLOYEES RETIREMENT SYSTEM OF TEXAS
TEXFLEX ENROLLMENT/CHANGE FORM
ERS FB 9.20 (R 5/2018)
Page 1 of 3
Only for participants with active employee benets.
SECTION A: EMPLOYEE DATA
Employee Name: SSN ERS Employee ID
Type of employee: o
9-month (higher education institutions) o 12-month
SECTION B: ACTION AND REASON CODE (Check only one box.)
FSC o Family Status Change HIR o New Hire REH o Rehire PHC o Post Hire Change LOA o Leave of Absence
RED o Reduction while on LOA RFL o Return from Leave
Enter a reason code and event date if you checked the FSC box above.
See the Family Status Change (FSC) Reference Chart on page 3 before completing.
Reason Code: Event Date: (mm-dd-yyyy)
You may complete your benets election either by:
• Using your online account at www.ers.texas.gov, or
• Sending this completed form to your benets
coordinator or HHS Employee Service Center for
employees at HHS Enterprise agencies
SECTION C: TEXFLEX HEALTH CARE ACCOUNT (Fill out only one of the three options in this section, if applicable.)
o TexFlex health care account – for eligible medical, vision and dental out-of-pocket costs excluding insurance premiums. Program has
a minimum annual pledge of $180 and a maximum annual pledge of $2,650 per tax year. Enrollment/change must be made within 31 days
of your employment or qualifying life event. You will receive a TexFlex debit card, at no cost, to pay for eligible expenses. There is no annual
administrative fee for the TexFlex health care account. Note: If you do not check this box, you will not be enrolled in this account.
OPTION 1: NEW ENROLLMENT (Complete only if New Hire/Rehire or Family Status Change.)
I want my monthly deduction to be (not to exceed $220 per month): $ .00
Number of months left in the plan year (September 1 – August 31): x
Annual pledge: $ .00
OPTION 2: INCREASE PLEDGE AMOUNT (Complete only if increasing pledge amount due to a Family Status Change.)
Current annual pledge amount: $ .00
Increase my annual pledge amount to: $ .00
OPTION 3: REDUCTION (Complete only if reducing pledge amount due to a Family Status Change.)
Current annual pledge amount: $ .00
Reduce my annual pledge amount to: $ .00
SECTION D: TEXFLEX DEPENDENT CARE ACCOUNT (Fill out only one of the three options in this section, if applicable.)
o TexFlex Dependent Care Account – for eligible child or adult dependent care expenses. Program has a minimum annual pledge of $180
and a maximum annual pledge of $5,000 or the lesser of your spouse’s or your annual income that is below $5,000. Enrollment/change must
be made within 31 days of your employment or qualifying life event. The TexFlex debit card is not available to pay for dependent care expenses.
There is no annual administrative fee for the TexFlex dependent care account. Note: If you do not check this box, you will not be enrolled in this
account.
OPTION 1: NEW ENROLLMENT (Complete only if New Hire/Rehire or Family Status Change.)
I want my monthly deduction to be (not to exceed $416 per month): $ .00
Number of months left in the plan year (September 1 – August 31): x
Annual pledge: $ .00
OPTION 2: INCREASE PLEDGE AMOUNT (Complete only if increasing pledge amount due to a Family Status Change.)
Current annual pledge amount: $ .00
Increase my annual pledge amount to: $ .00
OPTION 3: REDUCTION (Complete only if reducing pledge amount due to a Family Status Change.)
Current annual pledge amount: $ .00
Reduce my annual pledge amount to: $ .00
Information provided to ERS is maintained for managing your benets. If you
have questions about your information, or believe that information provided to
ERS may be incorrect, please notify ERS.
Authorization:
I understand my TexFlex health care, dependent care, and/or limited exible spending account enrollment is irrevocable for the
plan year, unless I have a qualifying life event, terminate employment or retire. I authorize payroll deductions for the amount listed
on this form.
I understand I have until August 31 to incur health care expenses for the plan year and can carry over a minimum of $25, up to $500
of my TexFlex health care account balance to the next plan year. Any amount over $500 will be forfeited.
I understand I have until August 31 to incur eligible dental or vision expenses for the plan year and can carry over a minimum of $25,
up to $500 of my TexFlex limited exible spending account balance to the next plan year. Any amount over $500 will be forfeited.
I understand I have until November 15 to incur dependent care expenses for the plan year. The carryover is not allowed for the
TexFlex dependent care account.
I must le all eligible claims for reimbursement by December 31 of the associated plan year.
I understand that TexFlex account eligibility, enrollment and benets information is available from my employer and at
www.ers.texas.gov. I certify that I have read and agree to all of the conditions and participation rules for this program.
Sign:__________________________________________________ Date:___________________________________________
Page 2 of 3
SECTION E: TEXFLEX LIMITED FLEXIBLE SPENDING ACCOUNT (Fill out only one of the three options in this section, if applicable.)
Enrollment in the TexFlex limited exible spending account (LFSA) is only applicable if you are enrolled in Consumer Directed
HealthSelect
SM
o TexFlex LFSA – for eligible dental and vision out-of-pocket costs excluding healthcare costs. Program has a minimum annual pledge
of $180 and a maximum annual pledge of $2,650 per tax year. You must enroll or make any changes within 31 days of your employment
or qualifying life event. You will receive a TexFlex debit card, at no cost, to pay for dental and vision expenses. There is no annual
administrative fee for the TexFlex LFSA. Note: If you do not check this box, you will not be enrolled in this account.
OPTION 1: NEW ENROLLMENT (Complete only if New Hire/Rehire or Family Status Change.)
I want my monthly deduction to be (not to exceed $220 per month): $ .00
Number of months left in the plan year (September 1 – August 31): x
Annual pledge: $ .00
OPTION 2: INCREASE PLEDGE AMOUNT (Complete only if increasing pledge amount due to a Family Status Change.)
Current annual pledge amount: $ .00
Increase my annual pledge amount to: $ .00
OPTION 3: REDUCTION (Complete only if reducing pledge amount due to a Family Status Change.)
Current annual pledge amount: $ .00
Reduce my annual pledge amount to: $ .00
Family Status Change (FSC) Reference Chart
A qualifying life event (QLE) is an eligible event that allows you to change your enrollment elections within 31 days of that event.
The following are QLEs that correspond with a particular change in your employment or family status. Remember, rules will
determine if you can enroll in or make your requested changes.
Event Qualifying Life Event (QLE) Example Reason
Employee Marital Status Change
Participant gets married MAR
Participant gets a divorce or an annulment DIV
Death of a spouse DOD
Dependent Status Change
Birth of a newborn child BIR
Participant adopts, fosters, or gets court-appointed guardianship of child ADP
Participant gains or loses dependents through death DOD
Dependent becomes eligible or loses eligibility for insurance coverage
(Example: Participant’s spouse is covering their child. The child lost eligibility for the
spouse’s insurance because the child does not attend school.)
DEP
Dependent is related by blood or marriage, and was previously claimed on the
participant’s income tax return, but is no longer eligible to be claimed on participants
income tax return
XMO
Child gets married DGM
Employment Status Change
Participant/Dependent employment status change ESC
Dependent becomes eligible for insurance after a waiting period DWP
Address Change that Changes
Dependent Eligibility
Dependent moves out of health or dental plan service area DMV
Medicare/Medicaid/CHIP Eligibility
Change
Participant/Dependent gains Medicare/Medicaid/CHIP eligibility MDG
Participant/Dependent loses Medicare/Medicaid/CHIP eligibility MDL
Signicant Change in Cost/
Coverage Imposed by Third Party
Signicant change in cost by dependent care provider SCC
Signicant change in cost/coverage of dependent’s health or dental plan (excluding GBP) SCC
HIPP approval or loss of eligibility SCC
Ofce of the Attorney General
(OAG) - Ordered Coverage Change
(Eligibility rules apply for these
dependents)
Participant gains requirement to provide coverage for child through a National Medical
Support Notice (NMSN) issued by the Ofce of the Attorney General (OAG)
(Example: employee receives an NMSN to provide health coverage for his child.)
MSO
Expiration of an NMSM, which is issued by the OAG and requires a participant to provide
coverage for a child.
(Example: employee’s NMSN to provide health coverage for his child expires and the
employee is no longer required to continue coverage for the child.)
MSD*
*Employees must contact their benets coordinator (HHS Enterprise employees contact HHS Employee Service Center) to drop dependents
added with a NMSN.
Benet changes must be consistent with the QLE. Dependent eligibility and enrollment rules apply.
Page 3 of 3
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Completed 27 July 2020

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