SBC: I hereby acknowledge receipt of the Summary of Benefits and Coverage (SBC) found in Ease. I have read the SBC and am familiar with its contents. If I have any questions concerning the information, I will contact the carrier or my Human Resources Department to have my questions answered. I understand this SBC is not a contract, and the material represents guidelines subject to change.

Offer of Coverage: I certify that I have received enrollment and plan information for health care coverage that HMIA offers, representing that it meets ACA requirements for affordable, minimum essential coverage, offering minimum value to me. I have been given the opportunity to enroll in or decline that coverage.

Pre-Tax Payroll Deductions: I authorize any payroll deductions required for the elections made in this online enrollment portal. I understand that these deductions will be made on a pre-tax basis unless I elect otherwise on this form. I understand that I cannot change my elections until the next open enrollment period, but I may change coverage for the dependents I am insuring or add new dependents if there is a "qualified" change in status. I have read the plan description and understand the post-tax deduction option.