This is your opportunity to change or enroll in benefits offered by TexasGulf FCU. Should you waive any benefit, you will not have the opportunity enroll again until the next Open Enrollment in 2017, unless you have an IRS qualifying event. IRS guidelines are listed at www.irs.gov
Please refer to your 2016-17 TexasGulf FCU Benefit Book for plan details, costs, and summary of benefits. If electing MEDICAL coverage please select a plan option and coverage level below
Please refer to your 2016-17 TexasGulf FCU Benefit Book for plan details, costs and summary of benefit. If electing DENTAL coverage please select a plan option and coverage level below.
Please refer to your 2016-17 TexasGulf FCU Benefit Book for plan details, costs and summary of benefits. If electing VISION coverage please select a plan option and coverage level below
TexasGulf FCU provides you with Life, Short and Long Term Disability Insurance benefits when you are hired. This coverage is provided at no additional cost to you.
Voluntary Life Insurance is offered as an optional benefit. If you elect an amount over the GI (guarantee Issue) amount you are subject to completeing an Evidence of Insurability (EOI) form. If you select yes, we will provide the form for you or you can visit www.unum.com to complete it online.
Please refer to your benefit book for rates and limitations. Below list amounts requested for yourself, spouse and eligible dependents.
You have elected to cover your dependent(s) for one or more of the benefits offered. In order for your dependent(s) to be enrolled you must complete the information shown below. This infomration is REQUIRED for your dependents to be covered. BE SURE TO INCLUDE birthdates and social security numbers for ALL dependents to be covered. Any missing information will keep us from enrolling your dependent(s).
I authorize my employer, TexasGulf FCU, to deduct the cost of any elected benefits for medical, dental or vision coverage from my pay on a pre-tax basis, as authorized under the Section 125 plan. I declare that all entries on this enrollment form are true and complete. 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 my dependents are not acively at work or unable to engage in 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, or my dependent resumes usual duties. A photographic/electronic 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 and election change within 31 days after such event.
I understand that my dependent(s) and I may be considered a Late Enrolee(s) subject to a longer preexisting condition exclusion limitation if we don't enroll when initally eligible.