<p> 2012 STEIN MART ENROLLMENT / CHANGE FORM</p><p>First Name: MI: Last Name: Soc. Sec. #: Store #: </p><p>Address: City: State: Zip: Date of Birth: </p><p>Single Married Male Female Position: FT Hire Date: Insurance Effective Date:</p><p>New FT Employee Marriage Birth or Adoption of Child Divorce Loss of other coverage Other Type of Enrollment: Special Enrollment – Please check reason New PT to FT Employee and give date Annual Open Enrollment Date of the event: ______Other event ______</p><p>I elect the Gold Plan Single Coverage Medical Coverage: I do not want medical coverage* I elect the Silver Plan Family Coverage</p><p>I elect the Red Plan Single Coverage Dental Coverage: I do not want dental coverage* I elect the Blue Plan Family Coverage Single Coverage Vision Coverage: I elect vision coverage I do not want vision coverage* Family Coverage</p><p>FLEXIBLE SPENDING ACCOUNT - Select one or both accounts and an annual deduction amount for each selection</p><p>Health Care Account Annual Deduction Amount ______(min of $120 and max of $2500/annually)</p><p>Dependent Care Account Annual Deduction Amount ______(min of $120 and max of $5000/annually if tax filing is single - or married /jointly, max of $2500 if married filing separately)</p><p>MEDICAL AND DENTAL INFORMATION List eligible dependents to be covered: </p><p>Dependent Name Social Sec. # Birthday Relationship Coverage Add Delete</p><p>Medical Dental Vision</p><p>Medical Dental Vision</p><p>Medical Dental Vision</p><p>Medical Dental Vision</p><p>LIFE INSURANCE Beneficiary: Soc Sec #: Address: Relationship to you:</p><p>DISABILITY INSURANCE FOR WEEKLY PAID ASSOCIATES ONLY: I elect I don’t elect* Disability Insurance * I UNDERSTAND THAT I WILL NOT BE PERMITTED TO REQUEST ENROLLMENT UNTIL THE NEXT OEN ENROLLMENT PERIOD, AND I MAY BE ASKED TO SUBMIT EVIDENCE OF INSURABILITY AT MY OWN EXPENSE AT THAT TIME.</p><p>I understand the choice(s) indicated above must remain in effect for the entire plan year unless I have a change in family status including the birth or adoption of a child, marriage, divorce, death of a spouse or dependent, or a spouse’s change of employment. </p><p>CERTIFICATION OF FORM: I HEREBY AUTHORIZE ANY PAYROLL DEDUCTIONS FOR ANY ELECTIONS ON THIS FORM TO BE MADE BY MY EMPLOYER AND ALSO STATE ALL INFORMATION PROVIDED ON THIS FORM IS ACCURATE </p><p>ASSOCIATE SIGNATURE: ______DATE: ______</p><p>SM 5050 (Updated 12/11) Send original to Human Resources office and place a copy in associate’s file 2012 RATE SHEET</p><p>YOUR COST Per Pay Period</p><p>MEDICAL through United Healthcare</p><p>Silver Plan With Health Risk Assessment (HRA) Without Health Risk Assessment (HRA) Single Weekly $31.39 Single Weekly $33.70 Family Weekly $81.93 Family Weekly $85.40</p><p>Single Semi-Monthly $ 68.00 Single Semi-Monthly $ 73.00 Family Semi-Monthly $177.50 Family Semi-Monthly $185.00 </p><p>Gold Plan Single Weekly $ 50.08 Single Weekly $ 52.39 Family Weekly $130.40 Family Weekly $135.02 </p><p>Single Semi-Monthly $108.50 Single Semi-Monthly $113.50 Family Semi-Monthly $282.50 Family Semi-Monthly $292.50 </p><p>DENTAL through Delta Dental</p><p>Blue Plan Single Weekly $1.44 Single Semi-Monthly $ 3.13 Family Weekly $4.34 Family Semi-Monthly $ 9.40 </p><p>Red Plan Single Weekly $3.23 Single Semi-Monthly $ 7.00 Family Weekly $8.15 Family Semi-Monthly $17.65</p><p>VISION through Humana/CompBenefits </p><p>Single Weekly $1.23 Single Semi-Monthly $2.67 Family Weekly $3.32 Family Semi-Monthly $7.20</p><p>DISABILITY through Lincoln Financial</p><p>(Optional - for weekly paid associates only – maximum $150.00 weekly benefit)</p><p>Weekly cost -- $3.33 Guaranteed coverage (subject to pre-existing conditions) during initial enrollment or Open Enrollment, otherwise, all new enrollees are required to provide evidence of insurability. One (1) year waiting period for pre-existing conditions, including pregnancy. Coverage must remain in effect for one plan year and may not be canceled or changed unless proof of a Family Status Change is provided. Qualifying events include marriage, birth/adoption, death of a dependent or spouse, spouse has a change in employment, dependent ceases dependent status, or initial eligibility for Medicare. A Benefits Enrollment/Change Form and proof must be provided to the Plan Administrator within thirty one (31) days of the date of the Family Status Change event, including newborns. </p><p>2012 Medical Plan Highlights Silver Plan Gold Plan Benefits In Network Out of Network In Network Out of Network Deductible Single $500 $750 $750 $750 Family $1,500 $2,250 $2,250 $2,250 Coinsurance 20% 40% 20% 20% Out-of-Pocket Limit Excludes Deductible Excludes Deductible Single $3,000 No limit to what you pay $4,000 No limit to what you pay Family $9,000 No limit to what you pay $12,000 No limit to what you pay Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Physician Services PCP Office Visits $25 copay 40% after deductible $25 copay 20% after deductible Specialist Visits $50 copay 40% after deductible $25 copay 20% after deductible Allergy Injections $5 copay 40% after deductible $5 copay 20% after deductible Preventive Care (w/o diagnosis) </p><p>Routine Physical Exam Covered at 100% 40% after deductible; $300 annual max Covered at 100% 20% after deductible; $300 annual max Well Woman/GYN Exam (w/o diagnosis)</p><p>Family physician Covered at 100% 40% after deductible; $300 annual max Covered at 100% 20% after deductible; $300 annual max Specialist Covered at 100% 40% after deductible; $300 annual max Covered at 100% 20% after deductible; $300 annual max Mammograms Covered at 100% 40% after deductible; $300 annual max Covered at 100% 20% after deductible; $300 annual max Well Child Care (w/o diagnosis) </p><p>Family physician Covered at 100% 40% after deductible; $300 annual max Covered at 100% 20% after deductible; $300 annual max Specialist Covered at 100% 40% after deductible; $300 annual max Covered at 100% 20% after deductible; $300 annual max</p><p>Hospital Services Inpatient $550 per admit then 20% of $500 per admit then 20% of eligible $750 per admit then 40% of eligible $550 per admit then 20% of eligible eligible expenses after expenses after deductible expenses after deductible expenses after deductible deductible Outpatient $200 per visit then 20% of $200 per visit then 20% of eligible $200 per visit then 20% of eligible 40% of eligible expenses after deductible eligible expenses after expenses after deductible expenses after deductible deductible </p>