8800 Old Main Hill Logan, UT 84322 PH: (435) 797-0122 FAX: (435) 797-1816 hr.usu.edu

Employee Demographics

Employee Name Employee A#

Sex Birthdate Date of Hire Social Security Number

Mailing Address, City, State, Zip

Campus Department Address

Preferred Email Address

Have you previously been a benefited employee at USU or another public institution of higher education in Utah? If so please provide employer name and job begin and end date:

Veteran Status (select one) Ethnicity (select one) Race (select one)

o Hispanic or Latino

o Not Hispanic or Latino

o N/A

o Vietnam Veteran

o Special Disabled Veteran

o Armed Forces Medal Veteran

o Other Protected Veteran

o American Indian or Alaska Native

o Asian

o Black or African American

o Native Hawaiian or Pacific Islander

o White

Emergency Contact Name

Emergency Contact Phone

Preferred Phone

Relationship

rev 05/01/2019

o Citizenship: US Citizen o Not a U.S. Citizen o Employment Authorization Type:

8800 Old Main Hill Logan, UT 84322 PH: (435) 797-0122 FAX: (435) 797-1816 www.usu.edu/HR

Policy Acknowledgement

Utah State University Policies can be found at https://www.usu.edu/policies/

Name: A#:

I, the undersigned, understand and agree that my employment is subject to all policies of Utah State University (“USU”). I understand and agree that I have the responsibility to understand and keep current with all USU policies. I understand and agree that USU’s policies and benefits are subject to change at USU’s sole discretion at any time and that such changes may supersede, modify, or eliminate policies existing at the time of my hire by USU. I agree to comply with all of USU’s policies that apply to me and my role as an employee of USU. I understand and agree to consult Human Resources and/or my supervisor regarding any questions I may have relating to USU policies.

Employee Signature: Date:

rev 11/15/2019

8800 Old Main Hill Logan, UT 84322 PH: (435) 797-0122 FAX: (435) 797-1816 www.usu.edu/HR

Beneficiary Designation for USU Death Benefits

In the event of an employee's death, the University will pay one month's salary from the date of death plus any unused annual leave to the beneficiary. This is in addition to any life insurance that the employee may have. This death benefit is a payment based on the deceased employee’s salary for a 30 day period from the date of the death.

Employee Name: A#:

Indicate below your beneficiary designation.

Primary Beneficiary Secondary Beneficiary

Employee Signature: Date:

rev 5/1/2019

Name:

Relationship:

SSN#:

DOB:

Phone Number:

Address:

Name:

Relationship:

SSN#:

DOB:

Phone Number:

Address:

8800 Old Main Hill Logan, UT 84322 PH: (435) 797-0122 FAX:

o I have never worked for USU. I understand I will be enrolled in a 401(a) retirement plan.

o I previously worked for USU and was in a 401(a) retirement plan with USU. I understand I mustgo back into the retirement program I was in at that time.

o I was enrolled in URS previously while working for USU. I understand I must remain in URS.

o I was enrolled in URS with another employer and wish to enroll with URS.

o I am a Post Retiree re-employed more than 60 days, but less than one year after URS retirement. Iunderstand I may be rehired in a position with no benefits, limited earnings, and cannot earn additionalservice credit.

o I am a Post Retiree re-employed more than one year after URS reretirement allowance and forfeit any retirement-related contributi

o I am a Post Retiree re-employed more than one year after URS reretirement allowance and return to active member status earningRe-employment retirees must work a minimum of two additional ybenefit. Retirees electing to continue to receive their pension mustemployer must sign Form RTRT-51 indicating your election.

I acknowledge my election and understand my employer fundedduring my employment with Utah State University.

Employee Signature:

Acknowledgment of Retirement Account Options & Election Form

Please complete this form within 30 days of hire. Employees who were previously employed with Utah State University and in a retirement program, must go back into the retirement program they were in previously. If you have never worked at Utah State University you will be enrolled in a 401(a) plan.

401(a) Option:

USU will contribute 14.2% of your annual gross earnings into a retirement account, called a 401(a) plan. You designate who will administer the contributions by completing the Retirement 401(a) Investment Provider Form found in the new hire packet. New employees are required to log in to TIAA and/or Fidelity in order to register in the employer funded retirement 401(a) plan. Instructions for logging into TIAA and/or Fidelity can be found on the Office of Human Resources website; hr.usu.edu.

Please mark the applicable statement:

ORUtah Retirement System (URS) Option:

Employees who previously worked for USU and were enrolled in URS while working for the University, must remain in URS. For employees enrolled in URS with another employer you may enroll with URS. Employees enrolled in URS prior to July 2011 are considered Tier 1, those enrolled after July 2011 are considered Tier 2.

Please mark the applicable statement:

(435) 797-1816 www.usu.edu/HR

tirement and wish to retain myons from the employer.

tirement and wish to cancel my additional service credit, if eligible.ears to qualify for an additional sign their URS form RTRT-27A. The

retirement election cannot change

Date:

Rev 5/1/2019

Retirement 401(a) Investment Provider Form

Employee Name: Employee A#

o TIAA - 100% Fidelity - 0%o TIAA - 90% Fidelity - 10%o TIAA - 80% Fidelity - 20%o TIAA - 70% Fidelity - 30%o TIAA - 60% Fidelity - 40%o TIAA - 50% Fidelity - 50%o TIAA - 40% Fidelity - 60%o TIAA - 30% Fidelity - 70%o TIAA - 20% Fidelity - 80%o TIAA - 10% Fidelity - 90%o TIAA - 0% Fidelity - 100%

· I authorize the University to send my retirement contributions as set forth on this form.· I understand that unless I contact the Investment Provider and request different investmentchoices, the funds will be invested in a target retirement date life-cycle fund based on mycurrent age and anticipated retirement at age 65. I understand that I may change myinvestment options by contacting the Investment Provider.· I understand that this change only affects money that will be contributed by the Universityafter this form is processed in the Human Resources Department. If I wish to transfer funds inmy account from one provider to another, I must contact the new provider to initiate thetransfer process.· I understand if my FTE drops below 50%, or if I terminate my employment with theUniversity, I will no longer be eligible for contributions, but my account will be maintained bymy selected Provider(s) and I may continue to make investment choices.· I understand that I must enroll online with the retirement vendor.

Employee Signature: Date:

In addition to this form, you are required to enroll online with the TIAA

and/or Fidelity 401(a) plan. Step by step guides can be found at:

hr.usu.edu/benefits/retirement/

rev 5/1/2019

Future Employer Distribution of University Contributions USU will contribute 14.2% of your annual gross earnings into a retirement account, called a 401(a) plan. You may choose TIAA or Fidelity Investments or both, as your retirement program. Providers allow you to designate how the contribution is invested among their respective investment options. If you do not make a selection, the default will be TIAA at 100%.

I hereby instruct Utah State University to direct all my future 401(a) Employer Defined Contribution Retirement Plan contributions to an account in my name with the following election.

Please select one:

rev 5/1/19

Medical and Dental Enrollment/Change Form

This form needs to be submitted within 30 days of your hire date or life event. The change in insurance will take effect on the day of the life event.

New Hire/Rehire Marriage Birth/adoptionLIFE EVENT DATE:

Loss/Gain other coverage Divorce / Term Partnership

DUAL COVERAGE

Do you have a spouse that is an employee of USU and you are electing a DUAL medical & dental plan? (If you are electing the DUAL plan please make sure to list your spouse’s information in the dependent section below)

Yes

No

Employee Signature:______________________________________________________________ Date:_____________________

EMPLOYEE INFORMATION

Gender Birthdate Date of Hire

Address, City, State, Zip

Email Address Phone

MEDICAL COVERAGE

PLAN SELECTION NETWORK SELECTION

High Deductible Health Plan (HDHP) (not eligible for DUAL) Preferred ValueCare (PVC) Network

Wellness Plan (White Plan) Participation (PAR) Network

High Premium Plan (Blue Plan) Medical Coverage - Level Election WAIVE MEDICAL COVERAGE Employee Only

Employee + 1

Employee + 2 or more

DENTAL COVERAGE

Employee Only

Employee + 1

Employee + 2 or more

DEPENDENTS*Please provide documentation of the relationship between the employee and dependent(s) listed below (e.g.copy of birth certificate, marriage certificate or adoption)

Name Dental Medical Sex Birthdate Social Security Number A# or F# Relationship

Employee A#Name (Last, First)

USU Dental PlanWAIVE DENTAL COVERAGE

PLAN SELECTION Dental Coverage - Level Election

I understand there is a Summary Plan Document (SPD), which is available to me at https://hr.usu.edu/benefits/healthcare/index. The SPD describes the terms and benefits of coverage available through Utah State University.

EVENT TYPE: (select one)

Name Employee A#

Additional Dependents

*Please provide documentation of the relationship between the employee and dependent(s) listedbelow (e.g. copy of birth certificate, marriage certificate, or adoption)

Name Dental Medical Sex Birthdate Social Security Number

A# or F# (if

applicable)

Relationship

403(b) Supplemental Retirement Auto Enroll

Opt Out Form

Opt Out of Participation (stop the deferral)

Effective ____________ (enter date), I elect to stop my salary deferral contributions under the

auto enroll provision of the Utah State University 403(b) Plan (the “Plan”). I understand that no

further salary deferral contributions will be made unless and until I sign a new Salary Deferral

Agreement.

I understand I can start contributing again to Utah State University supplemental retirement plans

at any time by signing a new Salary Deferral Agreement, available on the HR website or in the

HR Office.

Employee Signature: ________________________Print Name___________________________

Date: _________________________A # _____________________________

Human Resources: _________________________

Date: _________________________