I elect coverage as indicated when I complete the online enrollment process and consent to all terms and conditions stated. Furthermore, I declare that the information represented is true and correct. If contributions are required for my coverages, I authorize my employer to deduct such contributions from earnings via payroll deduction until future notice. My participation in the plan is subject to all the plan terms and conditions as set forth in the plan documents and Summary Plan Description.

SBC: I hereby acknowledge receipt of the Summary of Benefits and Coverage (SBC). 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 Resource 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 Milling Benson Woodward LLP 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 the online enrollment process. I understand that applicable deductions will be made on a pre-tax basis unless I elect otherwise in writing to my Human Resources Department. I understand that I cannot change my elections until the next open enrollment period, unless I have a qualified event/change in status and my election is consistent with such change.

Required Benefit Notices: Below is a link to the required benefit notices. I attest that I have read and understand the Required Benefit Notices.