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.
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).