Medical Plan Questionnaire

Have you used tobacco products (including, but not limited to, cigarettes, chewing tobacco, cigars, pipes, or e-cigarettes) during the 6 months immediately preceding the date of this Tobacco Declaration form? *

• I. If you answered “no” to the above “Tobacco Use Declaration”, you are eligible for the discounted non-tobacco user premium (hereafter referred to as “the discounted premium”) under the following conditions:
•         a) The discounted premium for non-tobacco users will be applied unless Rosenboom receives information that you have used tobacco products in the 6 months preceding this document and/or use tobacco products anytime following this declaration.
•         b) If you begin or resume using tobacco products following your completion of this Tobacco Declaration form, you must notify Human Resources, and the premium will increase to the standard non-discounted premium on the first of the month following Rosenboom’s receipt of this information.
• II. If you answered “yes” to the above “Tobacco Use Question”, you are not eligible for the discounted premium and must be charged the standard, non-discounted premium.
•         a) If you are tobacco free for 6 months, please contact Human Resources to begin the above discount.

By Signing this Tobacco Declaration form:
I certify that the statements and answers set forth are full, true, and correct to the best of my knowledge and belief, and that no information required to be given, either expressly or by implication, has been knowingly withheld. I understand that Rosenboom will rely upon the completeness and truthfulness of the information given and the statements made, and that if I made any false statements or misrepresentations, or have failed to disclose or concealed any material fact, Rosenboom will be entitled to increase the premium to the standard non-discounted premium. Rosenboom reserves the right to conduct testing to verify tobacco declarations are correct at any time, for any reason. Rosenboom reserves the right to discipline an employee providing false information up to and including dismissal.

A $70 monthly spousal surcharge (divided out bi-weekly into 26 pay periods) will be added to your premium if you have elected coverage for your spouse and your spouse is eligible for coverage through his/her employer as a full-time benefit but elects to enroll in a Rosenboom plan. If your spouse is eligible for coverage as a full-time Rosenboom employee, the spousal coverage surcharge is waived. *

If this form is not received by Human Resources and your spouse is enrolled in a Rosenboom health plan, you will be charged the surcharge until this form is received (nonrefundable). If your spouse loses or obtains health coverage through their employer as a full-time benefit, you have 31 days to notify Rosenboom’s Human Resources in writing of such change. My signature below indicates that the facts set forth on this form are true and complete to the best of my knowledge. I also understand that if my spouses group health insurance status changes, it is my responsibility to notify Human Resource in writing within 31 days of such change. Any false statements written on this form or on future forms as it relates to spousal health information shall be considered grounds for disciplinary action.

ACCESS TO DOCUMENTS:

I acknowledge that I have access to the documents below on the Employee Self Service website (ESS) or may request a hard copy of the same from a member of Human Resource:

• 2027 SBC HDHP Rosenboom Machine and Tool
• 2027 SBC Traditional Rosenboom Machine and Tool
• 2027 Employee Assistance Program SBC
• CHIP Notice
• Privacy Practices and Rights under HIPAA
• HIPAA Notice of Special Enrollment
• WHCRA Notice
• Principal HIPPA Notice

I understand that I can contact Human Resources if I have any questions.

Acknowledgement:

By acknowledging this document, I acknowledge that I understand and agree with the statements listed above. I also acknowledge that I have access to the documents listed in the above sections or may request a hard copy of the same from a member of Human Resources.

AUTHORIZATION & ACKNOWLEDGEMENT:

I understand that I must submit a claim and appropriate documentation (e.g. explanation of benefits, itemized bill) for out-of-pocket, Medical, Dental, Vision and/or Dependent Care expenses before I can be reimbursed. I certify that I will only submit claims for reimbursement under the Health Savings Account for eligible expenses incurred by myself or my eligible dependents, in accordance with the terms of the respective Health Savings Account Plan. I certify that I will not submit claims for reimbursement under the Health Savings Account for amounts that have already been reimbursed by another source nor will I seek reimbursement for such amounts from any other source.

AUTHORIZATION & ACKNOWLEDGEMENT:

I agree to have my gross salary redirected, in accordance with Section 125 of the Internal Revenue Code, to contribute in the amounts indicated. I understand that contributions to my reimbursement account(s) can only be reimbursed to me for eligible expenses incurred within each plan year. For example, funds in the Medical Reimbursement Account cannot be used for reimbursement of dependent care expenses. I further understand that if I do not use the funds in my reimbursement account(s) during the plan year, those funds will be handled in accordance to my current plan design offered by my employer.

I agree to have my gross salary redirected to pay my contributions/premiums for employer provided benefits I elect which are payable through the flexible benefits plan. I instruct my employer to make these contributions on my behalf. If my required contributions for the elected benefits are increased or decreased while this agreement remains in effect, I understand that my salary redirection will automatically be adjusted to reflect that increase or decrease.

AUTHORIZATION & ACKNOWLEDGEMENT:

I understand and agree with the following statements:

• My dependents are not eligible for any coverage for which I am not covered.
• My dependents, including stepchild(ren), foster child(ren) and those over the maximum age, are eligible for coverage based on policy provisions. Eligibility for my dependents over the maximum age will be verified when claims are submitted.
• If I cancel vision coverage, I or my dependents may enroll at a later date; however, enrolling late will affect the level of benefits.
• If I cancel any type of life or disability coverage, I may apply at a later date; however, I must provide proof of good health at my own expense and coverage will only become effective subject to approval from Principal Life Insurance Company.
• If I cancel coverage, I cannot under any circumstance enroll in the policy once I have retired.
• If the group policy requires that I make contributions, I authorize my employer to deduct them from my pay.
• If I knowingly provide false or misleading information, I may be guilty of insurance fraud, which is punishable by law.

Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, may be guilty of insurance fraud. I declare that the information I have completed on this change form is complete and true. I understand an agent or broker cannot guarantee coverage, revise rates, benefits, or provisions without written approval from Principal Life.

AUTHORIZATION & ACKNOWLEDGEMENT:

REPRESENTATION.
I have read or had read to me the completed application and understand that any misstatement or misrepresentation in the application may result in loss of coverage. I represent that statements and answers given on this application are true, complete, and correctly recorded.

UNDERSTANDING.
I understand that: if premiums for the coverage(s) is (are) to be paid by payroll deductions, these deductions may start before the "effective date" of coverage(s) and that this does not change the effective date of coverage; and the “effective date” for health insurance coverages will be the date recorded on the policy/certificate/benefit statement, not the date the application is signed. If the coverage(s) is (are) not issued, American Heritage Life will refund any deductions it receives. I also understand that no producer (agent) has authority to waive any answer or otherwise modify this application, or to bind AHL in any way by making any promise or representation that is not set out in writing in this application. I understand that if I refuse any coverage for which I am eligible, satisfactory proof of insurability may be required, at my own expense, should I desire to apply for it at a later date. Any such application may be declined on the basis of such proof.

PREMIUM DEDUCTION AUTHORIZATION (EMPLOYEE).
I AUTHORIZE my employer to deduct from my salary or wages, if applicable, the necessary premium for the coverages requested.

AUTHORIZATION TO OBTAIN AND DISCLOSE CERTAIN DATA (FOR LIFE AND CRITICAL ILLNESS).
I authorize any physician, medical practitioner, hospital, clinic or other medical facility, Pharmacy Benefit Managers, insurance company, MIB, Inc. or other organization, institution or person, that has records or knowledge of me or my health including my prescription medication history to give to AHL, its subsidiaries or its reinsurers any information. I also authorize AHL, or its reinsurers, to make a brief report of my health information to MIB, Inc. I understand that there is a possibility of redisclosure of any information disclosed pursuant to this authorization and that information, once disclosed, may no longer be protected by federal rules governing privacy and confidentiality. I acknowledge receipt of the Important Notice About Privacy and MIB Notice form. A copy of this authorization is as valid as the original. This authorization applies to any minor dependent on whom insurance is requested. This authorization is valid for 24 months from the date signed. I understand that I may revoke this authorization at any time by notifying AHL in writing of my desire to do so.