2022 Benefits Enrollment/Change Form

BASIC INFORMATION: PLEASE REPORT ANY CHANGES TO HUMAN RESOURCES IMMEDIATELY

Name Gender Date of Birth Social Security Number

Street Address City State ZIP

Marital Status
Date of Hire

REASON FOR ENROLLMENT

Type of Event (e.g., marriage, Date of
New Hire Qualifying Life Event
birth of a child, etc.) Event

MEDICAL COVERAGE: SELECT ONE PLAN AND COVERAGE TIER

COVERAGE TIER PPO HDHP COVERAGE TIER Kaiser HMO (CA Only)
Employee Only Employee Only
Employee + Spouse/
Employee + One
Domestic Partner*
Employee + Child(ren) Employee + Family
Employee + Family
Waive Medical

* SPOUSE/DOMESTIC PARTNER SURCHARGE YES NO

Does your covered spouse/domestic partner have access to medical coverage that meets essential health benefits
through his or her employer? An insurance plan that is certified by the Health Insurance Marketplace, provides essential
health benefits, follows established limits on cost-sharing (like deductibles, copayments, and out of pocket maximum
amounts), and meets other requirements under the Affordable Care Act.
I affirm that this statement is correct, and that if I answered “yes” and still choose to cover my spouse/domestic partner on Ajinomoto’s medical plan that I will be
charged $25 more per month for my medical premiums. I also recognize that if I answered this falsely , I may be subject to disciplinary action up to termination.

Signature

DENTAL AND VISION COVERAGE: SELECT ONE PLAN AND COVERAGE TIER FOR EAC H BENEFIT
DENTAL ViSION
COVERAGE TIER HMO BASE BUY-UP
PPO
(California Only) (Company-Paid Benefit) (Employee-Paid Benefit)

Employee Only

Employee + One

Employee + Family

Waive Dental Waive Vision

 HSA* LIMITED-PURPOSE FSA HEALTH CARE FSA DEPENDENT CARE FSA
(Health Savings Account) (Flexible Spending Account) (Flexible Spending Account) (Flexible Spending Account)
Only available with the HDHP Only available with the HDHP Only available with the PPO/HMO Available with any plan

Elect $________ annually Elect $________ annually Elect $________ annually Elect $________ annually
Decline Decline Decline Decline
Annual maximum you and
AFNA can contribute: $3,650
(employee-only coverage), $7,300 (all
other tiers) Annual maximum: $2,750 Annual maximum: $2,750 Annual maximum: $5,000

If you are age 55 or older, you can

increase the maximum by $1,000

Medical, dental and vision expenses Dental and vision expenses only Medical, dental and vision expenses Child and elderly day care expenses

* Annual employer contribution is $500 for employee only coverage and $1,000 for other family tier coverage. These amounts are prorated for new hires.

INCOME PROTECTION INSURANCE

Voya BASIC LIFE INSURANCE /AD&D - COMPANY PROVIDED (No Employee Cost)
One times your base annual salary up to $600,000
Employee Only (with age reduction benefits at age 65 and 70)

Voya OPTIONAL LIFE and AD&D INSURANCE Guaranteed Issue*

Election amount: _______ times annual salary Three times salary up

Employee Elect Waive
(One, two, three or four times annual salary, must not exceed $700,000) to $500,000
Election amount: _______,000
*Spouse (Increments of $5,000, must not exceed the lesser of 100% of employee’s Elect Waive $100,000
election or $150,000. Employee’s election includes basic and optional
coverage amounts.)

*Child (Unmarried Election amount: _______,000 Elect Waive $15,000

to age 26) ($5,000, $10,000 or $15,000 per child)

*Guarantee Issue applies at Open Enrollment and at new hire. Amounts over the guarantee issue will require evidence of insurability to be completed. If you are
increasing your greater than the guarantee , you will also require evidence of insurability. Please be sure to discuss with your HR representative.
Note: You must enroll in employee optional life coverage to be eligible to enroll ia spouse and / or child for optional life coverage..

Aflac Voluntary Benefits - CI cannot exceed 100% of employee election

Critical Illness Employee $10,000 Employee $20,000 Waive

Waive
Critical Illness Spouse $10,000 Spouse $20,000

Hospital Indemnity Low Plan High Plan Waive

Accident Employee Only Emp + Spouse Emp + Child(ren) Emp + Family

INCOME REPLACEMENT BENEFITS - Company Provided (No employee cost)

Short-term Disability: 60% of your base pay up to monthly maximum benefit amount set by the plan

Long-term Disability: 60% of your base pay up to monthly maximum benefit amount set by the plan
COVERED DEPENDENT INFORMATION: LIST ALL ELIGIBLE DEPENDENTS

GENDER DATE OF BIRTH SOCIAL SECURITY

FULL NAME (First, Middle Initial, Last Name)
(M/F) (MM/DD/YYYY) NUMBER
Spouse/Domestic Partner
Name:_______________________ Spouse OR Domestic Partner*
Child 1:
Name:_______________________ My Child OR Domestic Partner’s* Child
Child 2:
Name:_______________________ My Child OR Domestic Partner’s* Child
Child 3:
Name:_______________________ My Child OR Domestic Partner’s* Child
Child 4:
Name:_______________________ My Child OR Domestic Partner’s* Child

*Further documentation is required if covering a domestic partner or domestic partner’s children (ie. Domestic partner affidavit with proof of financial
interdependency and tax declaration)

BENEFICIARY INFORMATION: FOR BOTH VOLUNTARY AND COMPANY-PAID LIFE AND AD&D INSURANCE
FULL NAME SOCIAL SECURITY RELATIONSHIP
ADDRESS* PERCENTAGE**
(First, Middle Initial, Last Name) NUMBER TO YOU
Primary Beneficiary 1:

Primary Beneficiary 2:

Contingent Beneficiary 1:

Contingent Beneficiary 2:

* Address is required if SSN is not available. ** Primary beneficiaries must total 100%.

I authorize deductions from my earnings for any contributions required for coverage and I agree to make any necessary payments as required for coverage. I understand and agree that this Enrollment/Change Request may
be transmitted to authorized benefit carriers or their agents by my employer or its agent. I authorize any physician, other healthcare professional, hospital or any other healthcare organization (“Providers”) to give my
medical plan administrator (Ameriben/Blue Cross Anthem/Kaiser) or its agent information concerning the medical history, services or treatment provided to anyone listed on the Enrollment/Change Request form, including
those involving mental health, substance abuse and HIV/AIDS. I further authorize Ameriben/Blue Cross Anthem/Kaiser to use such information and to disclose such information to affiliates, Providers, payors, other insures,
third party administrators, vendors, consultants and governmental authorities with jurisdiction when necessary for my care or treatment, payment for services, the operation of my health plan, or to conduct related activi-
ties. I have discussed the terms of this authorization with my spouse and competent adult dependents and I have obtained their consent to those terms. I understand that this authorization is provided under state law and
that it is not an “authorization” within the meaning of the federal Health Insurance Portability and Accountability Act. This authorization will remain valid for the term of the coverage and so long thereafter as allowed by
law. I understand that I am entitled to receive a copy of this authorization upon request and that a photocopy is as valid as the original. The plan documents (Schedule of Benefits, Group Agreement, Certificate of Coverage,
Group Policy, Group Insurance Certificate) will determine the rights and responsibilities of member(s) and will govern in the event they conflict with any benefits comparison, summary or other description of the plan. I
understand that the amounts deducted from my pay and not used for eligible health care and/or dependent care expenses incurred the same plan year will be forfeited in accordance with IRS regulations.
I hereby apply for the coverage now being offered to myself and dependent(s), if any, as shown on this form. My employer is authorized to deduct the appropriate amounts from my earnings, as authorized under IRS
Section 125. I understand that any pre-tax amounts will not be subject to Social Security or federal/state income tax withholding, which may result in a reduction of future Social Security benefits to which I may be entitled.
I hereby declare that all entries on the front and rear of this form are true and complete and that any material misstatements or failure to report information may be used as the basis for recession of coverage for me and
my dependent(s) (if any) from the effective date.
Important Notice: If you refuse coverage for yourself, you automatically refuse coverage for any dependents. If you are declining enrollment for yourself and your dependents (including spouse) because of other heath
insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided you request enrollment within 30 days after your other coverage ends. Also you must indicate the reason for
declining enrollment. If you have a status change event, new dependent as a result of a marriage, birth, adoption, you may be able to enroll yourself and your dependents provided you request enrollment within 30 days
after the marriage, birth, or adoption.
I certify that the statements on this application and all information furnished by me are true and complete to the best of my knowledge. I understand that no right whatsoever is created by this application and that the
same shall not be considered accepted unless and until the contract is actually issued by the applicable carriers. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of a
crime and may be subject to fines and confinements in state prison.
Any person who with intent to defraud any insurance company or other person files an application for insurance or statements of claim containing any materially, false information or conceals for purpose of misleading
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and may also be subject to civil penalties, or denial of insurance benefits.
Please note that your signature below also confirms that you read, understood, and agree to the terms stated by Unum in the Accident and Critical Illness section on page two if you are electing either one or both of these
coverages.

EMPLOYEE USE—PAGE 3 OF 3 Signature Date