Please read all of the following system acknowledgement(s). To indicate your acceptance, please select the following acknowledgement check boxes and click the "I Acknowledge" button.

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Employee Access Acknowledgment v.1[Acknowledged on 05/22/2018]
When electronic signatures are used, federal law requires that we inform you of the following:

By clicking the "I Acknowledge" button below, I consent to electronic processing of this application to include use of my electronic signature.

I acknowledge that Electronic Signature means that I am the person identified on this application as the applicant, that I voluntarily accept all the terms and conditions as stated in this application, and that I agree to the electronic processing of this record. I acknowledge that my electronic signature will have the same legal effect as a signature on paper.

I acknowledge that I have the right to print and keep this application on paper.

I acknowledge that I have the right to withdraw my consent to the electronic signature on this application. I understand I must notify my benefit providers in writing of my withdrawal of consent and that such withdrawal will not affect actions already taken by my benefit providers.

I acknowledge that my consent to the use of my electronic signature applies to this application only and not to any other transactions with my benefit providers.

I hereby apply for coverage on the basis of the statements and answers to the questions herein. I hereby declare all answers to be true to the best of my knowledge and to accurately represent the health of those persons applying for coverage and waiving coverage. I understand that these statements, answers and subsequent information I provide are the basis for my coverage. Furthermore, I understand that this application must be updated by me to include any condition or disease which may occur between the date of my application and the Effective Date of Coverage. I understand that if my application for new or additional coverage is accepted, that applicable coverage will not be effective until after I am notified for the Effective Date.


I agree any elections made for Section 125 cannot be revoked or changed during the plan year, unless there is a change in my family status (eg. marriage, divorce, death of spouse or child, birth or adoption of child, and termination of spouse's employment) which justifies the revocation or change as authorized by the Internal Revenue Code and Regulations. I understand that my Social Security benefits may be affected by my participation in this plan. I understand that any moneys that I allocate in these accounts and do not spend by the end of the Plan Year cannot be returned to me as tax free compensation.

I understand that providing false information or omission of relevant information in this online application may result in the denial of claims cancellation or rescission of coverage. I also understand that the premium for deduction does not constitute coverage or approval by the carrier. Coverages that require health questions are not in force until approved by the insuring carrier.

APL - Electronic Delivery of Policy Documents v.2[Acknowledged on 05/22/2018]
I understand and agree to electronic delivery for the insurance carriers I choose during my enrollment that provide Electronic Delivery of Policy Documents. Policy Documents will be hosted on a secure website to which I will be provided access and instructions on how to and review or print my Policy Documents. I acknowledge that: I must provide a valid email address to the insurance carrier, and I must have a personal computer with internet access, an appropriate browser software, and Adobe Acrobat Reader®; if the Electronic Delivery requirements previously stated are not met, my Policy Documents will be sent via United States Postal Service; and, I may change this election at any time by contacting the insurance carrier or may receive a paper copy by contacting the insurance carrier at the address listed on the policy.
TRS Notice v.3[Acknowledged on 05/22/2018]
I am employed by the Employer named in this Enrollment Application and Change Form. I am eligible to participate in the coverage(s) offered by the TRS-ActiveCare program which is administered by Aetna, with HMO benefits provided by SHA, L.L.C. dba FirstCare Health Plan, Scott and White Health Plan, and Allegian Insurance Company dba Allegian Health Plans. On behalf of myself and any dependents listed on their Enrollment Application and Change Form, I apply for those coverage(s) for which I am eligible.
  • If I am enrolling a grandchild in Section 4, I certify that my household is the grandchild's primary residence and the grandchild is my dependent for federal income tax purposes for the reporting year in which coverage of the grandchild is in effect.
  • If I am enrolling a child as an "other Child" in Section 4, I certify that my household is the child's primary residence, that I provide at least 50% of the child support, that neither of the children's natural parents reside in my household, and that I have the legal right to make decisions regarding the child's medical care.

Only those coverage(s) and amount for which I am eligible will be available to me. I understand that if this Enrollment Application and Change Form is accepted, the coverage(s) will become effective in accordance with the provisions or the TRS-ActiveCare program.

I understand that by enrolling for coverage with Employer named in the Enrollment Application and Change Form that any TRS-ActiveCare coverage I previously elected under another TRS-ActiveCare participating district/entity will be terminated under TRS Rules.

I authorize necessary payroll deduction by my Employer, if any, to cover the cost of my coverage(s). I agree that my Employer acts as my agent. All notices given to my Employer are binding upon me. I also agree that my participation in the coverage(s) is subject to any future amendments.

I understand that by declining TRS-ActiveCare coverage now or by terminating TRS-ActiveCare coverage during the plan year, I am not eligible to re-enroll in TRS-ActiveCare until the next plan year, unless I experience a special enrollment event.

I state that the information given on the Enrollment Application and Change Form is true and correct. I understand and agree that any incorrect statements material to the risk and knowingly made by me will invalidate my coverage(s).

NBS Notice v.3[Acknowledged on 05/22/2018]
A health FSA paying or reimbursing section 213(d) medical expenses through a debit card must satisfy all of the following requirements - (1) Before any employee participating in a health FSA receives the debit card, the employee agrees in writing that he or she will only use the card to pay for medical expenses (as defined in section 213(d)) of the employee or his or her spouse or dependents, that he or she will not use the debit card for any medical expense that has already been reimbursed, that he or she will not seek reimbursement under any other health plan for any expense paid for with a debit card, and that he or she will acquire and retain sufficient documentation (including invoices and receipts) for any expense paid with the debit card.
Text Message Authorization v.1[Acknowledged on 05/22/2018]
By electing to receive text messages, I authorize my employer to send text messages to my cell phone to convey important HR information about employee benefits offered through my employer. I understand that standard text messaging rates may apply to any messages received from my employer. I also understand that I or my employer may revoke this permission in writing at any time. I agree not to hold my employer liable for any electronic messaging charges or fees generated by this service.
Google Translate Notice v.1[Acknowledged on 05/22/2018]
The alternate language translation which is part of this enrollment material was prepared by a third party vendor. MGM Benefits Group is not responsible for the accuracy of the alternate language translation. The administration of benefits will be in accordance with the terms and conditions set out in English. Any discrepancy between the English and alternate language versions will be resolved in accordance with the English language version provided herein. The English language version of these benefit materials controls.