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If you decline the company insurance benefit, it is required to submit the attached signed Waiver form (Medical,
Dental & Vision Enrollment Form-Page 3: E. Waiver of Coverage)

YOUR RESPONSIBILITIES DURING OPEN ENROLLMENT
If you don’t want to make any changes to your current benefit elections, and you do not participate in the
enrollment, you don’t need to take any action. All of your current benefit elections will automatically carry over
and remain effective for 2019.

If you want to make any changes to your current benefit elections, you will need to complete attached enrollment
form and submit to Mr. Chris Kim, HR, no later than [07/05/2019].

NOTE (qualifying event): After open enrollment, you cannot make changes to your coverage during the year
unless you experience a change in family status, such as:
 Loss or gain of coverage through your spouse
 Loss of eligibility of a covered dependent
 Death of your covered spouse or child
 Birth or adoption of a child
 Marriage, divorce or legal separation
 Switch from part-time employment to full-time employment

[Please find the attached]
 “BENEFIT GUIDE 2019”
- The benefit handbook includes Benefit eligibility, benefit summaries, rate, and how to find a doctor in
your area. The contact information for Insurance agency, Chun-Ha Insurance and each carrier’s member
service contacts are attached for you to contact whenever you need assistance. It also contains how to
log in to member portal. The purpose of the Employee Benefit Handbook is to provide information and
guidance to all employees to find a right plan and understand your plan.

 “Medical, Dental & Vision Enrollment Form(2019) ”.
- If you decide to add your dependent(s), additional premium due to adding dependent(s) will be at your
own cost.

 “Open Enrollment Overview and Summary ”.
- Benefit plans and rates.

 “Signed Waiver Form”.
- For declining coverage.

 Please refer the renewal effective dates : [ACI continues with same insurance companies]
Health: United Health Care 8/1/2019
Dental: United Health Care Dental 8/1/2019
Vision: Humana 8/1/2019

Chris Kim |Senior Vice President

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