Health Benefits Enrollment Form

1 This form is to be used by probationary/permanent new hire employees who are eligible for the below medical, dental and vision coverage Medical, Dental, and Vision Benefits Premium Contributions Kern Legacy Select Uses Kern Medical hospital and County-owned, Kern Health Care Network providers and contracted facilities. Kern Legacy Health Plan Network Plus Uses Kern Medical hospital and County-owned, Kern Health Care Network for both EPO and Plus tiers (includes Adventist Health Bakersfield Medical Center).County of Kern EPO Uses GemCare and Delano Medical Group providers with Dignity Health hospital and Permanente Uses Kaiser Permanente contracted physicians and facilities including Adventist Health Bakersfield Medical Center.

2 County of Kern POS Uses Anthem Blue Cross contracted providers and Vision and includes Vision and includes Vision and includes Vision and includes Vision and DHMO Dental PPO Dental DHMO Dental PPO Dental DHMO Dental PPO Dental DHMO Dental PPO Dental DHMO Dental PPO Dental BI-WEEKLY PREMIUM BI-WEEKLY PREMIUM BI-WEEKLY PREMIUM BI-WEEKLY PREMIUM BI-WEEKLY PREMIUM Employee only $ 0 $ 0 $ 37 $ 39 $ 44 $ 46 $ 47 $ 49 $ 83 $ 85 Employee + 1 $ 11 $ 14 $ 71 $ 74 $ 82 $ 85 $ 89 $ 92 $150 $153 Family (3 or more) $ 29 $ 32 $103 $106 $119 $122 $126 $129 $216 $219 Kern County Human Resources Health Benefits Enrollment Form IMPORTANT: Your completed New Hire Enrollment Packet and all required documentation must be received by Kern County Human Resources Health Benefits within 20 days of your hire date.

3 Fax or email forms are considered invalid and will not be processed. Please return completed forms to: Kern County Human Resources Health Benefits 1115 Truxtun Avenue 1st Floor, Bakersfield, California 93301 REQUIRED DOCUMENTATION FOR DEPENDENT Enrollment ALL Dependents: Social Security number must be listed on form. Spouses/ Domestic partners: A copy of a marriage certificate/registration form must accompany the Enrollment form. All Children: A copy of a birth certificate must accompany the Enrollment form PLUS (if applicable): For adopted children: Court documents indicating final adoption.

4 If the adoption is not final, court documents dated within the six months preceding an Enrollment request indicating the adoption is pending. If neither of these documents is available, contact Kern County Human Resources Health Benefits at (661) 868-3182. For Guardianships: Court documents indicating a guardianship has been established. For Foster Children: Court documents indicating current foster care placement. For a child over the age of 26 who is permanently disabled: Certification by a physician of the permanent disability. (Contact Kern County Human Resources Health Benefits at (661) 868-3182) DEPENDENTS ELIGIBILITY SUMMARY (SEE ELIGIBILITY POLICY FOR OFFICIAL ELIGIBILITY RULES) 1 Dependents age 26 or older who have never been covered by the plan may ONLY be enrolled upon employee s initial Enrollment .

5 An employee s initial hire date is their initial opportunity to enroll. If not enrolled upon the initial opportunity to enroll, they cannot be enrolled subsequently if they are age 26 or older. PLEASE NOTE: An incomplete form or failure to provide requested documentation will invalidate dependents Enrollment . Enrollment forms are subject to audit and additional documentation may be FOLLOWING DEPENDENTS ARE ELIGIBLE FOR COVERAGE Spouse/Domestic Partner: Employee s legal spouse or registered domestic partner Natural or Step Child: Child who is under the age of 26 OR Unmarried child age 26 or older who is permanently disabled 1 Adopted Child: Employee s or employee s spouse s or domestic partner s legally adopted child under the age of 26.

6 OR Employee s or employee s spouse s or domestic partner s unmarried legally adopted child age 26 or older who is permanently disabled 1 Guardianships: Unmarried child under the age of 26 for whom employee or spouse or domestic partner has legal guardianship, or had guardianship on the child s eighteenth birthday; OR Unmarried child age 26 or older for whom employee or spouse or domestic partner has legal guardianship and who is permanently disabled 1 COUNTY OF KERN Health PLAN Enrollment FORMP lease Print Clearly: Employee s Last Name First Name Middle Date of Birth Gender (M or F) Employee ID or SSN County Department: Daytime Phone Email Address Please indicate your choice of medical and dental plan by checking below.

7 See previous page for employee s bi-weekly contribution amount. Please select ONE medical and dental plan option:Kern Legacy Select - Effective 1/01/2018 Kern Legacy Health Plan Network Plus Kaiser Permanente County of Kern EPO Plan County of Kern POS PlanLiberty Independence PPO Dental Plan Liberty Cobalt Plus Dental Plan (DHMO) If you make no dental plan selection, you will be enrolled in Liberty Independence PPO Dental Plan. Package includes Vision Plan: Vision Service PlanPlease complete the following for yourself AND each dependent you are enrolling.

8 Additional supporting documentation is REQUIRED to enroll dependents (See page 2 for additional information). Note that a Primary Care Physician MUST be listed, if you are enrolling in Kern Legacy and the County of Kern EPO plan option. LAST NAME FIRST NAME MI DATE OF BIRTH GENDER (M or F) PRIMARY CARE PHYSICIAN (MCS EPO and Kern Legacy) EMPLOYEE EMPLOYEE SSN SPOUSE/DOM. PARTNER SPOUSE/DOM. PARTNER SSN CHILD CHILD SSN CHILD CHILD SSN CHILD CHILD SSN CHILD CHILD SSN CHILD CHILD SSN CHILD CHILD SSN TO BE COMPLETED BY KERN COUNTY HUMAN RESOURCES EMPLOYEE BENEFITSDate of Hire Plan Code Effective Date MF Are you or any of your dependents eligible for Medicare?

9 YES NO Is your spouse/domestic partner a Kern County employee? YES NO IF YES, provide his/her Social Security Number _____ - _____ - _____. Do you or any of your dependents have any other insurance? YES NO IF YES, please provide information: OTHER INSURANCE: Name of Spouse/Domestic Partner/ Dependent (Subscriber) Employer Individual or Family Coverage Name of Insurance Company ID Number/Group Number Phone Number EMPLOYEE CERTIFICATION _____ (initial) _____ (initial) _____ (initial) _____ (initial) _____ (initial) _____ (initial) _____ (initial)

10 I understand that any employee who obtains or continues coverage for any dependent who is not eligible for coverage, who obtains or continues County-paid coverage for any dependent who is not eligible for County-paid coverage, is subject to disciplinary action up to, and including, dismissal pursuant to Civil Service Rule 1700. Such employee shall also be liable to the County for the greater of (1) actual claims paid, and (2) other costs incurred by the County for coverage provided to the ineligible dependent.