Lawrence Berkeley National Laboratory Postdoc Benefits Plan
Enrollment, Change, Cancellation or Waiver Form
 

Fields marked with are required to print this form.

  1. Personal Information

LBNL ID Number

Last Name

First Name

MI

Gender

Date of Birth
mm/dd/yyyy
/ /
Social Security #

Home Phone

Home Address (Number, Street, City, State, Zip)

Postdoc Email Address

LBNL Phone

Mail Stop

Department

Job Title

Hire Date
mm/dd/yyyy
Total monthly salary/stipend

  2.Type of Action or Qualifying Event (Check all that apply) Type in date of event, if applicable.

 
[?]
New Hire
Date:
SSDP
 
OSDP
Same-Sex/Opposite Sex* domestic partnership either of the above registered with the State of California
Filing Date:
(if not registered, check "Add eligible family member".)
Delete family member - Specify family member in Sec 4
Date:
Select Reason:
If other, please specify:
Rehire Date:
Cancel coverage as below
Date:
Change personal data for eligible family member
Date:
Begin leave/furlough
Date:
Change in appointment status
Date:
Involuntary loss of coverage
Date:
(Please note that LBNL may require a letter from the employer verifying your and your family members' enrollment and coverage end dates.)
Return from leave/furlough - Date:
Add eligible family member
Date:
Other - specify:
Cancel previous opt-out request

  2a. Opt-Out of Coverage (Waiver)   I understand if I opt out of the LBNL - sponsored coverage, LBNL will not provide me or my family with dental or vision coverage.

I wish to decline coverage under the following plan(s): I am declining this coverage because (check one):
Dental Covered by another Plan
Vision Other (please specify)
 
Yes
No
I understand I am automatically enrolled in the Life, Short-Term Disability (STD) and Long-Term Disability (LTD).

  3. Benefit Coverage Options

3a. Principal POS Dental Plan
Uncheck Dental in section 2a to choose a Dental Plan.
3b. VSP Vision Plan
Uncheck Vision in section 2a to choose a Vision Plan.
Enroll Cancel
Enroll Cancel

  4. Individuals Covered - List individuals for whom you are enrolling or adding/changing coverage.

Check Action Desired            
Coverage Elected
Enroll Deenroll   Last Name First Name MI Gender Date of Birth Social Security #
Dental
Vision
Self
SAME AS ABOVE
SP/SS or OSDP*
Child
Child
Child
Child
Child

  *Spouse, Same-Sex or Opposite-Sex Domestic Partner

  PARTICIPATION TERMS AND CONDITIONS

Your social security number will be requested only when needed by benefit plan administration for financial reporting, or to verify your compliance with federal and state law.

As a participant in the LBNL sponsored Postdoc Benefit Plan (PBP), you agree to the following terms and conditions:

1. Most of the health plans that LBNL offers require resolution of disputes through arbitration. With regard to each plan, it is understood that any dispute as to malpractice, that is as to whether any services rendered under the contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to the contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. For more information about each plan’s arbitration provision, please see the appropriate plan booklet or call the plan.

2. LBNL plan vendors comply with the Health Insurance Portability and Accountability Act (HIPAA) and other federal/state regulations related to the privacy of personal information. To fulfill their contracted responsibilities and services, health plans and associated service vendors may share LBNL-PBP member health information between and among each other within the limits established by HIPAA and federal/state regulations for purposes of health care operations, payment and treatment. A member’s authorized restriction on the sharing of specified health information for health care operations, payment and treatment will be honored as required by HIPAA.

3. By making an election with your written or electronic signature, you are authorizing LBNL to take deductions from your earnings to cover your monthly costs, if any, for the plans you have chosen for yourself and your eligible family members. If I am a Postdoctoral Scholar-Fellow or Postdoctoral Scholar-Paid Direct, I agree to pay LBNL my monthly costs, if any, for the plans I have chosen.

4. You acknowledge and accept all terms and conditions of the LBNL-PBP plans in which you are enrolled as stated in the plan booklets.

5. If you enroll family members, LBNL, Garnett-Powers & Associates, Inc. and/or carriers may require proof of eligibility. Marriage or birth certificates, adoption papers, tax records, and the like may be requested. You agree to provide such documentation upon request.

6. If you enroll your eligible same-sex or opposite sex* domestic partner and/or your same-sex or opposite sex* domestic partner’s child(ren) or grandchild(ren), or if you enroll or have enrolled your natural or adopted child who is not claimed as your tax dependent, you acknowledge that the LBNL/employer contribution for their dental and/or vision coverage may be reported as income to you and (where appropriate) may be subject to the FICA (Social Security and Medicare) and/or federal and state income tax withholding.

7. If you specifically ask LBNL representatives and/or Garnett-Powers & Associates’ representatives to intercede on your behalf with your insurance plan, LBNL representatives and/or Garnett-Powers & Associates’ representatives will request minimum necessary health information required to assist you with your problem. If more protected health information is needed to solve your problem, in compliance with the state privacy laws and federal laws, including HIPAA (Health Insurance Portability and Accountability Act of 1996), you may be required to sign an authorization allowing LBNL and/or Garnett-Powers & Associates to provide the insurance plan with the relevant personal health information or authorizing the insurance plan to release such information to LBNL and/or Garnett-Powers & Associates.

8. Actions you may take during Open Enrollment will be effective the following January 1, unless otherwise stated.

9. You certify that all enrolled family members are eligible for coverage based on the definitions and rules according to LBNL’s eligibility requirements. You agree that you will de-enroll them within 31 days if they lose eligibility. You further certify that all the information you provide is true to the best of your knowledge, under penalty of perjury.

10. Making false statements about satisfying eligibility criteria, failing to notify LBNL of loss of eligibility within 31 days of such loss or failing to provide documentation when requested will lead to de-enrollment of the family members and possible legal action. In addition, postdocs may be subject to disciplinary action (e.g. loss of health benefits for up to 12 months) and will be responsible for any employer contributions to and benefits paid by the plan for the ineligible coverage.

11. I understand when I click ‘Submit’ below to submit my completed enrollment form, I am providing my electronic signature.

 

  CONTINUATION PRIVILEGES

For legal spouse, natural or adopted child, stepchild, legal ward, other child, and/or grandchild:
The consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) provides for the continued plan coverage for a certain period of time at monthly rates if you or your eligible family members lose group medical, dental, or vision coverage because you terminate your employment (for reasons other than gross misconduct); your work hours are reduced below the eligible status for those benefits; you die, divorce, or are legally separated, or because a child ceases to be an eligible dependent. Note: the continuation period is calculated from the earliest of these qualifying events and runs concurrently with other LBNL options for continued coverage. For more information, contact Garnett-Powers & Associates.

For same-sex or opposite sex* domestic partner or partner’s child/grandchild:
While not required under COBRA, LBNL’s health carriers have agreed to provide continuation coverage for same-sex or opposite sex* domestic partner, or a partner’s child/grandchild. Coverage may continue for a certain period of time at specified monthly rates if you or your eligible family members lose group medical, dental, or vision coverage because you die, because your relationship with a same-sex or opposite sex* partner ends, or because a partner’s child/grandchild is no longer eligible for coverage. Call Garnett-Powers & Associates for more information.

 

  HIPAA (Health Insurance Portability and Accountability Act of 1996) Notification of Medical Program Eligibility

If you are declining enrollment for yourself or your eligible family members because of other plan coverage, you may be able to enroll yourself and your eligible family members in a LBNL-PBP plan if you or your family members lose eligibility for that other coverage (or if the employer stops contributing toward the other coverage for you or your family members). You must request enrollment within 31 days after you or your family member’s other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a newly eligible family member as a result of marriage or domestic partnership, birth, adoption, or placement for adoption, you may be eligible to enroll yourself and your eligible family member(s). You must request enrollment within 31 days after the marriage or partnership, birth, adoption, or placement for adoption. If you do not enroll yourself and/or family member(s) within 31 days when first eligible, you may enroll at a later date. However, each member will need to complete a waiting period of 90 consecutive calendar days before medical coverage becomes effective, or you/they can enroll during the next Open Enrollment period.

To request special enrollment, or obtain more information, contact Garnett-Powers & Associates.

 

  *Opposite Sex Domestic Partner as defined by AB 205:

One or both of the persons meet the eligibility criteria under Title II of the Social Security Act as defined 42 U.S.C. Section 402(a) for old-age insurance benefits or Title XVI of the Social Security Act as defined in 42 U.S.C. Section 1381 for aged individuals. Notwithstanding any other provision of this section, persons of opposite sexes may not constitute a domestic partnership unless one or both of the persons are over the age of 62, eligible for social security benefits and the postdoctoral scholar and domestic partner are at least 18 years of age.

 

Lawrence Berkeley National Laboratory administers all benefit plans in accordance with applicable plan documents and regulations, custodial agreements, group insurance contracts and state and federal laws. No person is authorized to provide benefits information not contained in these source documents, and information not contained in these source documents cannot be relied upon as having been authorized by LBNL. Source documents are available for inspection upon request (1-844-315-4550). What is written here does not constitute a guarantee of plan coverage; benefits-particular rules and eligibility requirements must be met before benefits can be received.

Lawrence Berkeley National Laboratory intends to continue the benefits described here indefinitely; however, the benefits of all postdocs and plan beneficiaries are subject to change or termination at the time of contract renewal or at any time by LBNL or other governing authorities. LBNL also reserves the right to determine new premiums, employer contributions and monthly costs at any time. Health and welfare benefits are not accrued or vested benefit entitlements. LBNL’s contribution toward the monthly cost of the coverage is determined by LBNL and may change or stop altogether, and may be affected by the state of California’s annual budget appropriation.

 

I have read the general notice of COBRA Continuation Rights.

Yes
No
 

  Mutual of Omaha (United of Omaha) Designation of Beneficiary

 

Subject to the terms of the Group Contract(s), between United of Omaha Life Insurance Company and said policyholder, I request that the following beneficiary (beneficiaries) be substituted under said contract(s) as my designated beneficiary (beneficiaries), in lieu of any and all beneficiaries previously named by me:

Primary Beneficiary Designation

Name of Beneficiary
(First, MI, Last Name)

Related To Me As:

Date of Birth
(mm/dd/yyyy)

Address of Beneficiary
(Address, City, State, Zip)

Percentage

%
%
%
     
Percentage Total:
100%
 

Contingent Secondary Beneficiary Designation

Name of Beneficiary
(First, MI, Last Name)

Related To Me As:

Date of Birth
(mm/dd/yyyy)

Address of Beneficiary
(Address, City, State, Zip)

Percentage

%
%
%
     
Percentage Total:
100%

*If more than one named, the beneficiaries shall share equally unless otherwise stated above.

Unless otherwise above expressly provided, if any beneficiary listed above designated predeceases me, the share which such beneficiary would have received if such beneficiary had survived me shall be payable equally to the remaining designated beneficiary or beneficiaries, if any, who survived me, but if no designated beneficiary survives me, the beneficiary shall be determined as prescribed in said Group Contract(s).

This Designation of Beneficiary refers only to a Group Life Insurance contract.

This Designation of Beneficiary is subject to change as provided in said Group Contract(s).

The Life and Short-Term Disability Insurance are underwritten by United of Omaha Life Insurance Company.

  By clicking 'submit' below, the above beneficiary information has been recorded by policyholder on behalf of insurer and you are creating a printable document for your records.

  When you click the 'submit' button below, you will be submitting your enrollment form to a secure site and creating a printable document for your records.

  Submitting this document to our secure website constitutes a signature of compliance with all of the above.

 
I have read the Garnett-Powers & Associates Notice of Privacy Policy and Insurance Practices
Yes
No
 
Date: