Page * of *

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*. Personal Information

Please complete this section with all the necessary information. LAST NAME FIRST NAME MI

DATE OF BIRTH

SOCIAL SECURITY NUMBER

HOME / CELL NUMBER

STREET ADDRESS

CITY

STATE

ZIP CODE

Male Female Married Single

JOB TITLE

DATE OF HIRE

SALARY

PASSIVE ENROLLMENT: By checking this box my 2022- 2023 elections will roll over to 2023-2024. No changes need to be made at this time.

2. Your Legal Dependents

SPOUSE LAST NAME SPOUSE FIRST NAME M.I. DATE OF BIRTH SSN ADDRESS (IF DIFFERENT FROM EMPLOYEE) M

F

CHILD LAST NAME CHILD FIRST NAME M.I. DATE OF BIRTH SSN ADDRESS (IF DIFFERENT FROM EMPLOYEE ) M

F

CHILD LAST NAME CHILD FIRST NAME M.I. DATE OF BIRTH SSN ADDRESS (IF DIFFERENT FROM EMPLOYEE ) M

F

CHILD LAST NAME CHILD FIRST NAME M.I. DATE OF BIRTH SSN ADDRESS (IF DIFFERENT FROM EMPLOYEE ) M

F

3. Medical Coverage- (UMR/United Healthcare)

Rates are shown as Bi-Weekly

Medical Coverage Employee Only

Employee &

Spouse

Employee &

Children

Employee &

Family

Elect UHC Base Plan $27.69 $328.10 $328.10 $328.10

Decline Medical Coverage Reason for Declination: 4. Dental Coverage – Lincoln

Rates are shown as Bi-Weekly

Dental Coverage Employee Only Employee & Spouse

Employee &

Children

Employee &

Family

Elect Basic Plan $3.72 $12.49 $19.41 $28.65

Decline Dental Coverage Reason for Declination: Page 2 of 2

5. Vision Coverage – Lincoln

Rates are shown as Bi-Weekly

Vision Coverage Employee Only Employee & Spouse

Employee &

Children

Employee &

Family

Elect Basic Plan $3.47 $6.58 $7.71 $10.85

Decline Vision Coverage Reason for Declination: 6. Group Life AD&D – Paid for by the EMPLOYER- Mutual of Omaha Full time Employees are automatically enrolled in this benefit- $25,000 flat benefit 7. Voluntary Life- Paid for by the EMPLOYEE- Mutual of Omaha Employee Spouse Child(ren)

Elect in increments of $10,000

Max: Lesser of $300,000 or 5x annual salary

Elect in increments of $5,000

Max: $150,000

(not to exceed 50% of employee elections)

Flat amount of $10,000

(not to exceed 50% of employee elections)

Elect

Amount: $

Decline Voluntary Employee Life

Elect

Amount: $

Decline Voluntary Spouse Life

Elect

Amount: $

Decline Voluntary Child Life

Annual Increase Option: You may increase your benefit by $10,000 annually without submitting EOI. If you waived coverage during your initial eligibility period you or are increasing your benefit by more than $10,000 you will be required to submit evidence of insurability.

8. Beneficiary Designation

Primary Beneficiary

Name Relationship Percentage %

Secondary Beneficiary

Name Relationship Percentage %

I authorize TMC Laundry to deduct the cost of benefits for medical and dental coverage from my pay on a pre-tax basis, as authorized under IRS Section 125. I declare that all entries on this form are true and complete and that any material misstatements or failure to report information may be used as the basis for cancellation of coverage for me and my dependent(s) (if any) from the original effective date of coverage. If I am not actively at work or are unable to engage in all the usual duties of a person of like age and sex, the effective date of all non-medical coverage will be delayed until I return to work. A photographic copy of this authorization shall be valid as the original. I understand that elections (including elections not to participate) will continue for the entire plan year unless there is a change event as described in the 125 plan such as the formation of a new dependent relationship as a result of marriage, birth, or adoption or the dissolution of a relationship such as divorce, or loss of other coverage, I must request an election change within 31 days after such event. I understand that my dependent(s) and I may be considered a Late Enrollee(s) subject to a longer preexisting condition exclusion limitation if we don’t enroll when initially eligible. Employee Signature: Date:

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