Employee Enrollment Form for 403(b) Thrift Plans With Designated Roth Contributions
EMPLOYER’S NAME
EMPLOYEE HIRED
EMPLOYER NUMBER
If this employee ever worked on a part-time basis, enter the date on which the 1,000-hour requirement was met, in accordance with plan specifications.
If during the last three years this employee had service with another eligible organization that is to be counted toward meeting eligibility requirements, enter the number of months of such service that are to be counted.
EMPLOYEE’S SALARY RATE
EMPLOYEE’S DEPARTMENT # (IF APPLICABLE) $
EFFECTIVE DATES
Enter the effective date and the percentages of salary or dollar amount for Traditional Pre-tax and Designated Roth Contributions (after-tax) in the applicable areas. c (A)nnual c (B)iweekly c (M)onthly
TRADITIONAL PRE-TAX CONTRIBUTIONS
EMPLOYER CONTRIBUTIONS PERCENT OF SALARY DOLLAR AMOUNT EFFECTIVE DATE EMPLOYER MATCHING EMPLOYER NON-MATCHING EFFECTIVE DATE EFFECTIVE DATE % OR $ / // / / /
DESIGNATED ROTH CONTRIBUTIONS (AFTER-TAX) PERCENT OF SALARY DOLLAR AMOUNT EFFECTIVE DATE
SECTION 1 - EMPLOYEE
INFORMATION
SECTION 2 - ALLOCATION OF CONTRIBUTIONS
Show the percentage of your contributions you want to place in the Interest Accumulation Account of our General Account and/or Separate Account investment funds. Use whole numbers only, and make sure the percentages total 100%.
Amounts placed in the Interest Accumulation Account will be credited with the rate of interest applicable to that account. Your balance in any investment fund will fluctuate to recognize investment results.
Interest Account
_____% Mutual of America Interest Accumulation Account
Separate Account Investment Funds
Separate Account – Equity Funds (24)
_____% MoA Equity Index Fund
_____% MoA All America Fund
_____% MoA Small Cap Value Fund
_____% MoA Small Cap Growth Fund
_____% MoA Small Cap Equity Index Fund
_____% MoA Mid Cap Value Fund
_____% MoA Mid-Cap Equity Index Fund
_____% MoA International Fund
_____% Fidelity® VIP Mid Cap Portfolio
_____% Fidelity® VIP Equity-Income Portfolio
_____% Fidelity® VIP Contrafund® Portfolio
_____% Vanguard VIF Diversified Value Portfolio
_____% Vanguard VIF International Portfolio
_____% Goldman Sachs VIT US Equity Insights Fund
_____% Goldman Sachs VIT Small Cap Equity Insights Fund
_____% LincolnFinancialLVIPAmericanCenturyCapitalAppreciationFund
_____% American Funds Insurance Series® New World Fund®
_____% Macquarie VIP Small Cap Value Series
_% DWS Capital Growth VIP
_____% Invesco V.I. Main Street Fund®
_____% MFS® VIT III Mid Cap Value Portfolio
_____% Neuberger Berman AMT Sustainable Equity Portfolio
__% T. Rowe Price Blue Chip Growth Portfolio
__% Victory RS Small Cap Growth Equity VIP Series
Separate Account – Asset Allocation Funds (3)
___% MoA Conservative Allocation Fund
_% MoA Moderate Allocation Fund
_____% MoA Aggressive Allocation Fund
SECTION 3 - BENEFICIARY DESIGNATIONS
Separate Account – Fixed Income Funds (5)
__% MoA US Government Money Market Fund
__% MoA Intermediate Bond Fund
__% MoA Core Bond Fund
__% PIMCO VIT Real Return Portfolio
__% Vanguard VIF Total Bond Market Index Portfolio
Separate Account – Real Estate Fund (1)
__% Vanguard VIF Real Estate Index Portfolio
Separate Account – Retirement Funds (12)
__% MoA Retirement Income Fund
__% MoA Clear Passage 2020 Fund
__% MoA Clear Passage 2025 Fund
__% MoA Clear Passage 2030 Fund
__% MoA Clear Passage 2035 Fund
__% MoA Clear Passage 2040 Fund
__% MoA Clear Passage 2045 Fund
__% MoA Clear Passage 2050 Fund
__% MoA Clear Passage 2055 Fund
__% MoA Clear Passage 2060 Fund
__% MoA Clear Passage 2065 Fund
__% MoA Clear Passage 2070 Fund
Separate Account – Balanced Funds (3)
__% MoA Balanced Fund
__% Fidelity® VIP Asset Manager 50% Portfolio
__% Calvert VP SRI Balanced Portfolio
If you are married, you must name your Eligible Spouse (as defined in the Plan and federal law) as your only beneficiary unless your Eligible Spouse signs the Spouse’s Waiver of Death Benefits below in the presence of a Plan (employer) representative or a notary public after you designate the beneficiaries you wish below. Whenever you want to change your beneficiaries, your Eligible Spouse must sign a new waiver unless you name your Eligible Spouse as your only beneficiary. If you are younger than 35 when you name alternative beneficiaries with the consent of your Eligible Spouse, your beneficiary designation will automatically terminate when you attain age 35 and your Eligible Spouse will be your beneficiary unless you again designate alternative beneficiaries with a new signed waiver from your Eligible Spouse. If you are unmarried, you may name any beneficiaries you wish. If you marry in the future, your beneficiary designation under the retirement plan will be automatically voided. At that time, you should complete Mutual of America’s “Beneficiary Designation” form and follow the instructions applicable to married participants.
In the event of your death, and subject to the Eligible Spouse Waiver requirements, the total value of your account will be paid to the person or persons you name as your primary beneficiary. If no one you have named as a primary beneficiary survives you, the person(s) you name as your secondary beneficiary will receive the death benefit. If there is no living designated beneficiary at your death, the amount payable will be paid to the first surviving class of the following: (a) your surviving spouse (as determined under state law), (b) your surviving children in equal shares, (c) your surviving parents in equal shares, (d) your surviving brothers and sisters in equal shares, or (e) the executors or administrators of your estate.
If you name more than one primary beneficiary, or more than one secondary beneficiary, the death benefit will be paid in equal shares to the primary beneficiaries who survive you, or if none, to the secondary beneficiaries who survive you, unless you show below the percentage you want each of them to receive. If you specify percentages you want each beneficiary to receive, be sure your percentages for all beneficiaries in each beneficiary type total 100%.
Name your primary and secondary beneficiaries in the space provided. If you need more space, attach a page showing for each beneficiary the information asked for below. Please add your Employer’s name and Employer number, your signature and the date.
X
Beneficiary Type: c Primary c Secondary Relationship: c Spouse c Child c
Beneficiary Type: c Primary c Secondary Relationship: c Spouse c Child c Parent c Estate c Other
Are you married? c Yes c No
NOTE: Mutual of America and/or your employer may require evidence that you are not married if their records indicate that you are or were previously married.
If you are married and have not designated your spouse as primary beneficiary, the Spouse’s Waiver Section below must be completed.
SPOUSE’S
WAIVER (Witnessed by a Notary Public or Authorized Representative of Employer)
My spouse is a participant in a Mutual of America Thrift Plan under which I am entitled to be the beneficiary. As the beneficiary, I would receive a death benefit after my spouse’s death. However, I agree to waive my right to be the beneficiary. I agree to let my spouse designate the beneficiary or beneficiaries named on this form.
Spouse’s Name Date of Birth
Signature of Spouse Date
Signature and Seal of Notary Public or Signature of Authorized Representative Date Mutual of America employees are not authorized to sign as Plan representatives. Notary’s acknowledgment may be added below:
SECTION 4 - STATEMENT AND SIGNATURE
I have read the current prospectus and other materials describing the plan and after careful consideration I have found the plan to be suitable for my financial needs. Therefore, I elect to participate in the Thrift Plan.
EMPLOYEE’S SIGNATURE DATE
401(k), 403(b) or TAX-DEFERRED ANNUITY PLAN SALARY REDUCTION AGREEMENT
EMPLOYEE NAME
The Plan has been explained to me, and I have been given a Summary Plan Description. I understand that I may voluntarily choose to have my pay reduced for contributions to the Plan.
ELECTION TO CONTRIBUTE
I elect to designate my contributions as Traditional Pre-Tax Contributions and/or Designated Roth Contributions (after-tax contributions) as follows:
•
• Designated Roth Contributions (after tax): I elect to contribute ______% or $________________ of my pay, and I authorize my employer to deduct that amount each pay period.
I am aware that:
1)My contribution may be reduced in order to comply with Federal tax rules and limits, including any higher limits that apply to participants age 50 or older.
2)This election will take effect with the first pay period beginning on or after the first day of the next month, or as soon as it is administratively feasible for my employer to begin deductions from my pay after I file this Salary Reduction Agreement with my employer. I may stop or change my election for future pay periods by giving my employer written notice, which will take effect as soon as administratively feasible.
3)My contributions and earnings cannot be withdrawn or paid until I attain age 59½ or upon my death, disability or termination of employment. My contributions may be available for withdrawal in the event of serious financial hardship (according to the Plan and IRS rules).
4)Any portion of my contributions that I elect to be Designated Roth Contributions are after-tax and will be subject to regular income tax as part of my regular taxable pay. Distributions of Designated Roth Contributions will not be taxable when distributed from the Plan, but distributions of earnings may be subject to tax or penalty if not qualified. A qualified distribution is a distribution made (a) at least five years after I began Designated Roth Contributions and (b) after I have attained age 59½, become disabled or died.
5) Any election to treat all or part of my contribution as Designated Roth Contributions is irrevocable once the contributions are deducted from my pay.
6)This election generally applies to all compensation payments that I receive, as described in my employer’s Plan document.
EMPLOYEE SIGNATURE
EMPLOYER REPRESENTATIVE
ELECTION NOT TO CONTRIBUTE
DATE
DATE RECEIVED
I do not wish to contribute to the Plan at this time. I understand that if the plan provides for matching employer contributions, I will not be entitled to such contributions during the time I am not contributing. I also understand that I may elect to contribute in the future by completing a Salary Reduction Agreement and an Enrollment Form and filing them with my employer.
EMPLOYEE SIGNATURE
EMPLOYER REPRESENTATIVE
NOTE TO EMPLOYERS
DATE
DATE RECEIVED
THIS FORM SHOULD BE RETAINED WITH THE EMPLOYER’S RECORDS OF THE PLAN.
EMPLOYERS SHOULD REVIEW THIS SAMPLE PAYROLL AUTHORIZATION FORM WITH LEGAL COUNSEL, IN PARTICULAR REGARDING ANY APPLICABLE STATE LAW THAT MAY AFFECT THIS DOCUMENT.
ENROLLMENT/CHANGE FORM
GROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper)
Name of Group Customer/Employer
The Salvation Army - Eastern Territory (Officers) Group Customer # 121080 Report # Sub Code Branch
Date of Hire (MM/DD/YYYY)
Coverage Effective Date (MM/DD/YYYY)
YOUR ENROLLMENT INFORMATION (To be Completed by the Employee)
Name (First, Middle, Last)
Address (Street, City, State, Zip Code)
Date of Birth (MM/DD/YYYY)
Phone # Email Address New Enrollment Change in Enrollment If due to a Qualifying Event, enter event date (MM/DD/YYYY)
I have read my enrollment materials and I request coverage for the benefits for which I am or may become eligible. I understand that no contributions are required for Basic Life, Basic AD&D, Dependent Child Life and Dependent Child AD&D. I understand that contributions are required for the benefits I select below.
If you are currently enrolled and increasing your Voluntary Life amount by more than one level, you must complete a Statement of Health form.
If you are enrolling after the initial enrollment period and enrolling in Voluntary Life for the first time for an amount more than $10,000, you must also complete a Statement of Health form.
Term
Life Insurance & Accidental Death
Basic Life 1 and Basic AD&D
&
Dismemberment (AD&D) Insurance
Voluntary Life 1 and Voluntary AD&D $10,000 $25,000 $40,000 $75,000 $100,000 $150,000
Voluntary Dependent Spouse 2 Life 1,3 and Voluntary Dependent Spouse AD&D
Dependent Child Life 3 and Dependent Child AD&D
Voluntary Dependent Child Life 3 and Voluntary Dependent Child AD&D
Have you smoked cigarettes, pipes or cigars or used tobacco in any form in the past one year? Employee: Yes No
Dependent Information
If you are applying for coverage for your Spouse and/or Child(ren), please provide the information requested below:
Name of your Spouse (First, Middle, Last) Date of Birth (MM/DD/YYYY)
Name(s) of your Child(ren) (First, Middle, Last)
Check here if you need more lines. Provide the additional information on a separate piece of paper and return it with your enrollment form.
1 Life Insurance may include an Accelerated Benefits Option under which a terminally ill insured can accelerate a portion of his or her life insurance amount. An interest and expense charge may be deducted from the accelerated payment. Receipt of accelerated benefits may affect eligibility for public assistance. This benefit may be taxable and you are advised to seek assistance from a personal tax advisor.
2 For Vermont and Washington State residents, Spouse includes your registered Domestic Partner if you and your Domestic Partner are registered as domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available.
3 Amounts will be subject to state limits, if applicable.
4 Full Time Student means your dependent child, age 18 or older, enrolled as a full-time student in an accredited college, university, secondary school, or a vocational or trade school. Age limits will be subject to state limits, as applicable.
GEF02-1
ADM
(The form number above applies to residents of all states except as follows: Form number GEF09-1 applies to residents of Montana; GEF02-1
ADM applies to residents of Connecticut, North Dakota and Utah)
SUBMISSION INSTRUCTIONS
After completion, make a copy for your records and return the original to your Employer.
BENEFICIARY DESIGNATION FOR EMPLOYEE INSURANCE
I designate the following person(s) as primary beneficiary(ies) for any amount payable upon my death for the MetLife insurance coverage applied for in this enrollment form. With such designation any previous designation of a beneficiary for such coverage is hereby revoked I understand I have the right to change this designation at any time. I also understand that unless otherwise specified in the group insurance certificate, insurance due upon the death of a Dependent is payable to the Employee.
Check if you need more space for additional beneficiaries and attach a separate page. Include all beneficiary information, and sign/date the page. Full Name (First, Middle, Last)
Address (Street, City, State, Zip)
Full Name (First, Middle,
DECLARATIONS AND SIGNATURE
By signing below, I acknowledge:
1. I have read this enrollment form and declare that all information I have given is true and complete to the best of my knowledge and belief.
2. I declare that I am actively at work on the date I am enrolling and, if I am enrolling for any contributory life insurance, that I was actively at work for at least 20 hours during the 7 calendar days preceding my date of enrollment. I understand that if I am not actively at work on the scheduled effective date of insurance, such insurance will not take effect until I return to active work.
3. I understand that, on the date dependent insurance for a person is scheduled to take effect, the dependent must not be confined at home under a physician’s care, receiving or applying for disability benefits from any source, or Hospitalized. If the dependent does not meet this requirement on such date, the insurance will take effect on the date the dependent is no longer confined, receiving or applying for disability benefits from any source, or Hospitalized Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.
4. I understand that if I do not enroll for life coverage during the initial enrollment period, or if I do not enroll for the maximum amount of coverage for which I am eligible, evidence of insurability satisfactory to MetLife may be required to enroll for or increase such coverage after the initial enrollment period has expired. Coverage will not take effect, or it will be limited, until notice is received that MetLife has approved the coverage or increase.
5. I authorize my employer to deduct the required contributions from my earnings for my coverage. This authorization applies to such coverage until I rescind it in writing. 6. I affirmatively decline coverage for any benefits for which I am eligible which I do not request on this enrollment form.
7. I have read the Beneficiary Designation section provided in this enrollment form and I have made a designation if I so choose.
8. I have read the applicable Fraud Warning(s) provided in this enrollment form.
New York (only applies to Accident and Health Insurance): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
GEF09-1
DEC
(The form number above applies to residents of all states except as follows: Form number GEF09-1 applies to residents of Montana; GEF09-1
DEC applies to residents of Connecticut, North Dakota and Utah)
SUBMISSION INSTRUCTIONS
After completion, make a copy for your records and return the original to your Employer.
