Open Enrollment for Sowjanya Meenige (6071852)Initiated On: 05/05/2015Submit Elections By: 06/22/2015Event Date: 06/22/2015

Total Employee Cost/Credit$420.14 Semi-monthly Cost

Employee ResponsibilityPrint this page for your records. You are responsible for the cost of the proper employee share ofyour elected benefits. A payroll error does not absolve you of responsibility for payment of theproper share of the cost.

Elected Coverages

Benefit Plan CoverageBegin DateDeductionBegin Date Coverage

CalculatedCoverage Dependents Beneficiaries Employee Cost (Semi-monthly)

Employer Contribution(Semi-monthly)

Medical - United HealthCare Wellness Plan

07/01/2012 06/04/2012 Family Karthik R JellaMutyam Jella

$190.93 $718.26

Dependent Care Flex - ASIDependent Flex

07/01/2015 06/15/2015 $5,000.00Annual

$208.33

Medical Flex - ASI MedicalFlex

07/01/2015 06/15/2015 $500.00Annual

$20.83

Basic Life - Aetna FullTime (Employee)

07/01/2013 06/17/2013 $20,000 $20,000.00 Mutyam Jella $0.48

Accidental Death andDismemberment (AD&D) -Aetna AD&D - State(Employee)

07/01/2015 06/15/2015 $5,200 $5,200.00 Karthik R JellaMutyam Jella

$0.05

W-2 Elections - State ofNebraska W-2 Election

07/01/2014 06/16/2014 Yes

Total: $420.14 $718.74Waived Coverages

Plan TypeDentalVisionHSA

Benefit Plan Provider Website Requires BeneficiaryBeneficiaries

Beneficiary Primary Percentage /Contingent PercentageAccidental Death and Dismemberment (AD&D) - AetnaAD&D - State (Employee)

Aetna Yes Karthik R Jella ContingentPercentage

100

Mutyam Jella PrimaryPercentage

100

Basic Life - Aetna Full Time (Employee) Aetna Yes Mutyam Jella PrimaryPercentage

100

Electronic SignatureYour name and password are considered your electronic signature and serve as your confirmation of theaccuracy of the information submitted. When you mark the I AGREE checkbox, you are certifying thatyou have read and understand the following provisions:

I understand that health care elections made during this enrollment session are effective July 1,2015- June 30, 2016 and remain in effect for the rest of the Benefit Plan calendar year unless I havea qualifying change in status.

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I understand that any dependents I have enrolled in health coverage must meet the State ofNebraska's eligibility guidelines. I understand failure or inability to verify my dependent(s) eligibility,for any reason may result in disciplinary action up to and including termination of employment. Inaddition, any dependent(s) who I fail to verify will be removed from coverage.

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I understand that stepchildren can only be covered by a Family Tier. (Employees MAY NOT electcoverage for stepchildren without covering the biological parent also).

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I understand health, dental, vision, health savings account and flexible spending deductions are pre-tax while basic life, accidental dealth and dismemberment, supplemental life insurance and long termdisability deductions are post-tax.

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I understand that any comments submitted with my benefit(s) election process will not alter orchange any benefit(s) election(s) I have made during this process.

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I understand that Summary Plan Descriptions/Certificates of Coverage will serve as official sourcedocument(s) and prevail over any other plan descriptions.

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I understand that I may be subject to life insurance limitations and have made my election(s)accordingly.

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I understand that Life insurance increases (subject to evidence of insurability) and decreases as welll

Submit Elections Confirmation 09:45 AM05/19/2015Page 2 of 3

as beneficiary designations can be made at any time during the year.I understand that payroll deductions are taken for the pay period in which coverage is effective;retroactive deductions will be taken if the effective date for my enrollment is in the past.

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I understand that it is my responsibility to review and understand all information presented in thisbenefits election process.

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I understand that if I enroll in the Wellness Health Plan during Open Enrollment or as a New Hire andfail to meet the THREE STEP criteria, I will automatically be defaulted to the Regular Plan at theappropriate tier, based on the effective date, which will result in a premium adjustment.

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I understand that by making a HSA election, I agree to the terms outlined in the Authorized AgentAgreement.

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I understand that it is my responsibility to print and keep a copy of my benefit confirmation page.lSigned By: Sowjanya Meenige (6071852)

Date: 05/19/2015

Submit Elections Confirmation 09:45 AM05/19/2015Page 3 of 3