LE ea cs WAKE FOREST _ DEFINED CONTRIBUTION RETIREMENT UNtvEnsiTY PLAN ENROLLMENT FORM : \ston-Sal 9 muna paid: [] Monthy (2Biweekly Employee Name: “Lyd Davis. 8 WFU 1D Number: — _ Phone Ext sity to submit my contributions made bythe University on mY behalf, to the Funding hereby request and authorize Wake Forest Univers \Vehicte indicated below: SECTION Il - NEW ENROLL ry Payrott EFFECTIVE DATE: «Defined Contribution plan, you must complete an enrollment appicaton for one of the Funding forms are in the SRA packet provided by HR. Fidelity, TIAA-CREF for Vanguard nd HR USE ONLY 4 If you are a new enrotiee in the Yeple ‘vendors listed below along with this form. The 7, | nave submitted my vendor enraliment forms drecly (0 nave attached the vendor enrollment fons to ths form and a8h HR to forward AUTHORIZED FUNDING VEHICLE v bi (check ove) TIAA-CREF wo (por Ele Fidelity Investments a k ] Term TIAA Record ei C = \ a | Vanguard Group a fEctentinareara ee [oe Bie, oe PAYROLL EFFECTIVE DATE: ‘SECTION Iil= CHANGE ELECTION: 1s woutd ket change he destination of my curent Wee Foes conrbutons 4 Jaroady have an exsting account with ore ofthe folowing Funding Vehicles below —— IETS PTE ‘CURRENT ie Evecrion ‘AUTHORIZED FUNDING VeHIcLE | CHANGE To HR USE ONLY yt g __TIAACR ao) a a ian cod a ___ Fidelity Investments a ___ Vanguard Group signature - - Benefit Representative Date PO Box 7424 | Winston-Salem, NC 27109 | p 336.758.4700 | 336.758.6127 | askhr@wtu ediBenefits Enrollment Form WAKE FOREST 1 Ret 68 mere Sem se om Homan Resor z erent ervonel ta forenntion vernneren nani | Dans Tyre ser LO yp Rapainee tee [PMV twrmaner | Fete 37% mthty (94 4 tne premisas sappy We your payilldedcine Wf yout Hpouae ess ack dire pares oe ces sa coverage thn aogh wx nie reployer and yn, echt il hat inthe Was Focest medial plan Aton! Sealy are wade oe PA nnn caerng my penne pte on te Wake Fone med an share waned Seles Lam cineing mp ope parc on Hae Wake Forest ma pak ute does have aac os empneeenal stars camerage alte dar ot woth else el emplyed. he she employed et WU Raynedda Campos (astcharge ann 1am coring iy spr partnet on the Wa Foret medical asa he has ace to eda sverage th her empha wutcharge l py ew taneane [ tmplayce nly alge) EC bmphnee Only cae) Eine Sang comers Fnplijee@ speane Parner Value) [> Enplipe Spouse Parner Cone) anc Caverage E Setect Fis lee 8 Chald Value) f Egle & che one Piura iene Empire : Employee Oni (Lom Employee On Og sng Cove oa Empohe ane Pains gh Tee” tig, ARE npr dace Every coverages | Frplee hen tm) Enfonescinen fa e aly aoe) 1 Fama Tiigh) Vision Plan j a oa ci seco, F Ith [eee ne ain FEST tre ee Pie i Namie: Last, First, Middle {nitial SSN “7 Date of Buth Gender Medical Dental Viuon time ricK eeee n/t PYON PYPN ryee FYON rye PYPN PYPN rye FYPN YPN FYPNS Sede Bors cers res P.0.Box 7424: Winuon Sales. NC27109: 3367544700 £3367586127 brwfusty AdklIRe fursfark Vinca sop pennanimam) hamatinnnl 4 |G) pnd Cae 38000 acm) Ann Hs mo ‘Legal Plan Enrollment ie ance geceating Covecae tumate Advisor Le SoBe eee F ph te ag re Supplemental lagurance — dy ove hr cd cre re a i it Ml oxi the Ada web tp/leainent secon ascaunea Aisoetes omepaae np ia se ler cee eee tne us te Fee ocr von in Care Tisarance : Te det tw coverage change ov cans existing ortage ot fer additonal mation pene contact Gener a 00-6 3624 or wa the Gemoth website ipsam gsinarh mle troup d= wakeforet (etc eon 1 tamimrotdandwitiguteenlne Wan ened thst tei occ oy ln Dc a uarel terre rmerenen ol receiiee neetesrtc nel sex domestic [Gaui ndSathneciocmenomaemntnnesenete tome ence ire Pane ay rine! from coverage. Supporting docementaion & requires, I dsoppine sacra eae fete remburseten wb eked faked sea a ee Fem ss Pecoteme [| as Saeasonaenanaas, cS ssi bs preommanc arson PRE Tas Premium Plan “= | Rronung tela let are premigs for my medica, medical surcharge depth, vision, x pig coun Tal Sipplemental Neal Coverage Ase dedres Bom pay ona pre-tax\iss, Premiums all be deduced ong ny rear sorepaamn opi the bal and wil coninuc ales fcc okermse: undead at a Satan ere ih gen aie fone ta aaa ag ny Bay ta asa eg mIBe and any eb dependents as irted on this form and authorie my empl per to deduct fr sein eer a abet pe om shal or crn ang mat Bene upp enn ioe cl yet ead apa er cet feels Mtns arate cae pcrmammin elie el Fee ny ena tae apt ong Nene Spare of Braub polisyholder a summary of claims incurred by my eligible depends nea? vis auth valid f Se ee Tee glia aaa cachet on tata or ie Seat Seuetlnaue genet tape hata i at rian Senet typo aaa ng recede et bs Perel by cers pupae prow oraubenset S aeert eee Tov pe spite ta cl or eta aes caneg pn ray Bereta own Rone enact capensis nd ‘Promptly of any changes to the information contained in this application, niveraity atv the carr Signe: faql~ ‘my