09:45 AM

05/19/2015
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Submit Elections Confirmation

Open Enrollment for Sowjanya Meenige (6071852)

Initiated On: 05/05/2015
Submit Elections By: 06/22/2015
Event Date: 06/22/2015

Total Employee Cost/Credit

$420.14 Semi-monthly Cost

Employee Responsibility
Print this page for your records. You are responsible for the cost of the proper employee share of
your elected benefits. A payroll error does not absolve you of responsibility for payment of the
proper share of the cost.
Elected Coverages
Benefit Plan
Medical - United Health
Care Wellness Plan
Dependent Care Flex - ASI
Dependent Flex
Medical Flex - ASI Medical
Flex
Basic Life - Aetna Full
Time (Employee)
Accidental Death and
Dismemberment (AD&D) Aetna AD&D - State
(Employee)
W-2 Elections - State of
Nebraska W-2 Election

Coverage
Begin Date

Deduction
Begin Date

Coverage

07/01/2012

06/04/2012

Family

07/01/2015

06/15/2015

07/01/2015

06/15/2015

07/01/2013

06/17/2013

$5,000.00
Annual
$500.00
Annual
$20,000

07/01/2015

06/15/2015

$5,200

07/01/2014

06/16/2014

Yes

Calculated
Coverage

Dependents

Beneficiaries

Contribution
Employee Cost (Semi-monthly) Employer
(Semi-monthly)

Karthik R Jella
Mutyam Jella

$190.93
$208.33
$20.83

$20,000.00

Mutyam Jella

$5,200.00

Karthik R Jella
Mutyam Jella

$0.48
$0.05

Total:

Waived Coverages
Plan Type
Dental
Vision
HSA<=54
Optional Supplemental Life
Dependent Life
Long Term Disability (LTD)

Beneficiary Designations

$718.26

$420.14

$718.74

09:45 AM
05/19/2015
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Submit Elections Confirmation

Beneficiaries
Benefit Plan

Provider Website

Requires Beneficiary
Beneficiary

Accidental Death and Dismemberment (AD&D) - Aetna Aetna

AD&D - State (Employee)

Yes

Karthik R Jella
Mutyam Jella

Basic Life - Aetna Full Time (Employee)

Aetna

Yes

Mutyam Jella

Primary Percentage /
Contingent Percentage
Contingent
Percentage
Primary
Percentage
Primary
Percentage

100
100
100

Electronic Signature
Your name and password are considered your electronic signature and serve as your confirmation of the
accuracy of the information submitted. When you mark the I AGREE checkbox, you are certifying that
you have read and understand the following provisions:
I understand that health care elections made during this enrollment session are effective July 1,
2015- June 30, 2016 and remain in effect for the rest of the Benefit Plan calendar year unless I have
a qualifying change in status.
I understand that any dependents I have enrolled in health coverage must meet the State of
Nebraska's eligibility guidelines. I understand failure or inability to verify my dependent(s) eligibility,
for any reason may result in disciplinary action up to and including termination of employment. In
addition, any dependent(s) who I fail to verify will be removed from coverage.
I understand that stepchildren can only be covered by a Family Tier. (Employees MAY NOT elect
coverage for stepchildren without covering the biological parent also).
I understand health, dental, vision, health savings account and flexible spending deductions are pretax while basic life, accidental dealth and dismemberment, supplemental life insurance and long term
disability deductions are post-tax.
I understand that any comments submitted with my benefit(s) election process will not alter or
change any benefit(s) election(s) I have made during this process.
I understand that Summary Plan Descriptions/Certificates of Coverage will serve as official source
document(s) and prevail over any other plan descriptions.
I understand that I may be subject to life insurance limitations and have made my election(s)
accordingly.
I understand that Life insurance increases (subject to evidence of insurability) and decreases as well

Submit Elections Confirmation

09:45 AM
05/19/2015
Page 3 of 3

as beneficiary designations can be made at any time during the year.

I understand that payroll deductions are taken for the pay period in which coverage is effective;
retroactive deductions will be taken if the effective date for my enrollment is in the past.
I understand that it is my responsibility to review and understand all information presented in this
benefits election process.
I understand that if I enroll in the Wellness Health Plan during Open Enrollment or as a New Hire and
fail to meet the THREE STEP criteria, I will automatically be defaulted to the Regular Plan at the
appropriate tier, based on the effective date, which will result in a premium adjustment.
I understand that by making a HSA election, I agree to the terms outlined in the Authorized Agent
Agreement.
I understand that it is my responsibility to print and keep a copy of my benefit confirmation page.

Signed By: Sowjanya Meenige (6071852)

Date: 05/19/2015