TERMS AND CONDITIONS

To review a specific Term and Condition, click the name of the insurance carrier/benefit plan, which will take you directly to the appropriate page.

CAPITAL HEALTH PLAN/MEDICAL

FLORIDA BLUE/MEDICAL

DELTA DENTAL & DAVIS VISION

ARAG/LEGAL SERVICES

METLIFE/ACCIDENTAL DEATH AND DISMEMBERMENT

METLIFE/TERM LIFE INSURANCE

METLIFE/LONG TERM DISABILITY

FLEXIBLE SPENDING ACCOUNTS

CAPITAL HEALTH PLAN/MEDICAL

FLORIDA BLUE/MEDICAL

BLUE CROSS BLUE SHIELD OF FLORIDA/MEDICAL

CONTINUED

DELTA DENTAL & DAVIS VISION

ARAG/LEGAL SERVICES

AUTHORIZATION

By indication on the online system, I am requesting enrollment, cancellation or a change in the legal plan. I understand that the change in coverage will not become effective until the date assigned by the underwriter of the plan. I authorize my employer to deduct or cancel deductions for the cost of the plan as indicated on the online system, and as may be modified or adjusted, from my wages or salary.

CNA/LONG TERM CARE

METLIFE/ACCIDENTAL DEATH AND DISMEMBERMENT

METLIFE/TERM LIFE INSURANCE

METLIFE/LONG TERM DISABILITY

BLANET FRAUD WARNING

FLEXIBLE SPENDING ACCOUNTS

I understand my elections for a Health and/or Family/Dependent Care Flexible Spending Account are binding for the remainder of the current plan

year.

I understand that at no time during the plan year may I change my Health Care Flexible Spending Account election amount even if I experience an IRS

Qualifying Event.