Online Benefits Enrollment/Change Request

Confirmation

Insperity Contact Center: 866.715.3552 (weekdays, 7 a.m. to 7 p.m. CT)  Insperity PremierTM: portal.insperity.com

This confirms that you submitted your online request for enrollment/change in coverage under the Insperity® Group
Health Plan on the date shown below:
Date Online Request Submitted: 5/8/2023 1:59 PM
Confirmation No: ELRTZIHUM6

Employee Identification
Employee Name: Matthew Wayne King
Employee Identification No: 4245004
Employee Address: 419 ARBOR ST / SAINT PAUL / MN / 55102
Client Company No: 5281200
Client Company Name: TWINCOM, INC.

Your Benefits Enrollment

Enrollment Type: New Enrollment
Coverage Effective Date*: 08/06/2023
Elected Medical Coverage Tier: Employee
Elected Dental/Vision Coverage Tier: Employee

*Your Coverage Effective Date shown on this confirmation page is calculated based on information available to Insperity at
the time of your online enrollment. Any documentation or information received after your online enrollment was submitted
that changes your employment or enrollment data (such as a different hire date) may result in a revised Coverage Effective
Date. As a result, the Coverage Effective Date provided in the written confirmation of enrollment that Insperity will mail to
you should be considered your Coverage Effective Date of record.

Please review carefully your benefits enrollment election(s) listed below. If you need to make any changes, and are still within
your enrollment eligibility period, please visit Benefits under My Account of Insperity PremierTM and make your changes online.
If you are unable to make changes to your election online, please contact the Insperity Contact Center by phone toll-free at
866.715.3552 (weekdays, 7 a.m. to 7 p.m. CT), or by email at contactcenter@insperity.com.

If needed, you may correct or make changes to any of your personal information (i.e., address, telephone number, client
company name, etc.) online at portal.insperity.com, or by contacting the Insperity Contact Center Changes to your personal
information can be made any time, regardless of whether or not you are still within your eligibility period.

To help explain the coverage you have elected, Insperity provides an easy-to-understand Summary of Benefits and Coverage
(SBC) that includes important information about your elected coverage option, presented in a standardized format to make it
easy to compare across options, and a uniform Glossary that defines commonly used terms. These and other important
documents are available online in Insperity Premier at portal.insperity.com under Benefits. You may also call at the Contact
Center at 866.715.3552 to request that copies of Insperity SBCs and/or the Glossary be sent to you free of charge.

In addition to this online confirmation page, you will also receive a mailed Group Health Plan enrollment confirmation letter from
Insperity for the benefits coverage(s) you have elected. This letter will contain important information about your COBRA
benefits continuation rights that you should retain for your records.

Please see Page 2 of this confirmation for your health care benefits coverage election(s) or change(s) and a list of the dependents
you have selected to cover (or drop from coverage).

Client No. 5281200 Employee ID No. 4245004

Page 1 (Rev. 03-02-23) #

 Online Benefits Enrollment/Change Request
Confirmation

Health Care Benefits Coverage you Elected or Changed:

Effective Date
of Election
Coverage Type Coverage Option Group No. or Change Status
Dental UnitedHealthcare Dental PPO 50 701648 08/06/2023 Added

Vision VSP Vision Service Plan 701648 08/06/2023 Added

Medical UnitedHealthcare Choice Plus 1000 701648 08/06/2023 Added

Individuals you Selected to be Covered or Terminated from Coverage:

Effective Date
Social Security Date of of Election
Participant Name No. Gender Birth Relationship or Change Medical Dental/Vision
Matthew Wayne King XXX-XX-XXXX 12/31/1977 Employee 08/06/2023 Added Added

1. Employee attested that this dependent is under one year of age. Please provide a Social Security Number for this dependent as soon as
one is obtained.
2. Employee attested that this dependent is a non-resident alien, and is therefore exempt from the requirement to provide a Social Security
Number.
3. Employee attested that this dependent either is presently or was previously enrolled in Medicare Part A or B. This dependent’s Social
Security Number is required to complete Insperity’s Group Health Plan enrollment records – please provide as soon as possible.
4. Employee attested that this dependent is not a non-resident alien and neither presently nor previously enrolled in Medicare Part A or B.
IMPORTANT: If any enrolled dependent loses eligibility under the Insperity Group Health Plan, it is your responsibility to notify Insperity of such
change as soon as possible.

Employee E-Signature Matthew Wayne King

Premier
Date Signed 5/8/2023 1:59 PM Time Zone Central Standard Time Login gnomeworks

Page 2 (Rev. 03-02-23)

 Terms and Conditions
Group Health Plan

Your electronic signature acknowledges that you have read and agreed to the following Terms and Conditions and that all information
and statements provided in the online enrollment process (including with respect to you or your dependents’ eligibility) are accurate
and complete to the best of your knowledge and belief.
• I am requesting the enrollment/change designated. I agree to pay any required contributions, and authorize all applicable
reductions from my compensation in payment of any required contributions. I further understand that the deductions I have
authorized from my pay will include deductions for any contributions owed by me for coverage beginning on the effective date
regardless of when this form is submitted.
• I have been provided the opportunity to enroll based on having satisfied all eligibility requirements at the time coverage takes
effect. If I never become an employee under the terms of my employment agreement with Insperity, or otherwise do not meet
the eligibility requirements, I will not be covered under the plan. This enrollment request does not constitute a contract to
provide group health plan coverage.
• I understand that any material misstatements, misrepresentations or omissions (including with respect to my own or my
dependents’ eligibility) may result in coverage being void as of its effective date. I also understand that the failure to notify
Insperity of an enrolled dependent’s loss of eligibility may result in the retroactive termination of coverage as of the date of such
loss.
• I understand that all coverage elected is subject to the terms of the Insperity Group Health Plan, including applicable insurance
documents. The Summary Plan Description and Insurer Benefits Description can be found on Insperity PremierTM at
portal.insperity.com. A copy of the documents may be sent free of charge by contacting the Insperity Contact Center by calling
866-715-3552 (weekdays between 7a.m. and 7 p.m. CT), or email contactcenter@insperity.com.
• If I have elected high deductible health plan (HDHP) coverage, I also authorize the transmission of identifying data to Insperity’s
health savings account (HSA) vendor. If I choose to make HSA contributions through the HSA Program, I authorize the reduction
of my compensation on a pre-tax/post-tax basis (as applicable) for any required HSA contributions.
• I understand that the reduction in my compensation authorized pursuant to these Terms of Participation will be in addition to
any reductions under other agreements or benefits plans.
• I understand that I cannot change or revoke my enrollment election (including an election of no coverage) until the next open
enrollment period, unless a mid-year election change event occurs that lets me cancel or change my election mid-year.
• If eligible, I elect to participate in the Insperity Group Health Plan Cafeteria Plan, and authorize Insperity to reduce my
compensation on a pre-tax basis by an amount equal to my required contribution for coverage. If not eligible for cafeteria plan
participation, my compensation will be reduced on an after-tax basis by an amount equal to the required contribution for
coverage.
• I understand that I will not be eligible to participate in the Insperity Group Health Plan Cafeteria Plan if the Plan Administrator
determines that I do not satisfy the eligibility rules of the cafeteria plan as of the date my election would have been effective, and
in such case Insperity will treat as taxable income any pre-tax contributions made while ineligible.
• I understand that the Plan Administrator (in its discretion and with or without my consent) may deem taxable any or all of my
contributions at any time to the extent it deems appropriate for compliance with applicable law or the terms of the applicable
plan.
• I understand that the amount of my required contribution for coverage (and corresponding compensation reduction) is subject to
change, and that the administrator for the applicable plan may change or cancel the amount of my compensation reduction in
accordance with the terms of such plan(s), in its sole discretion and to the extent it deems appropriate for compliance with
applicable law or the terms of such plan(s).

State Required Acknowledgments of Waived Health Benefits

Hawaii Residents. If you waive medical coverage and you live in Hawaii, you must complete and return to Insperity the State of Hawaii
Form HC-5 Employee Notification to Employer. Employees who waive medical coverage and who live in Hawaii will be required to
complete and return a Form HC-5 annually. Insperity will provide Hawaii employees with the HC-5 form as applicable.
Other States/Municipal Entitles Which Require Acknowledgments of Waived Benefits. If you waive medical coverage and you live or
work in one of the states or municipal entities listed below, you may be required to complete a specific form to acknowledge that you
have waived coverage upon your initial eligibility for enrollment, and each year thereafter in which medical coverage is waived. Such
forms are required only if your client company is subject to or covered under a specific Health Care Ordinance. Please ask your
company if you are required to complete one of the following forms. Your company will maintain these forms for their records. You are
not required to submit a copy for Insperity’s records.
• Massachusetts – Employee Health Insurance Reporting and Disclosure Form
• San Francisco – Employee Voluntary Waiver
• Vermont – Vermont Department of Labor Declaration of Health Care Coverage

Insperity Contact Center: 866.715.3552 (weekdays, 7 a.m. to 7 p.m. CT)  Insperity PremierTM: portal.insperity.com

(Rev. 11-01-19) #