ARGON ST OPEN ENROLLMENT FORM (2008 Plan Year)

Please submit form to Cathy Rudd (San Diego), Jana King (Mountain View), or Tawanna Lockhart (all other locations).
A. EMPLOYEE INFORMATION
Employer or Group Name: Argon ST, Inc.
Work Location (Select One):
Doylestown, PA Mountain View, CA Smithfield, PA Windber, PA
Fort Walton Beach, FL Newton, PA Tampa, FL UAE
Iraq Redlands, CA Ventura, CA ✘ Home Office
Lexington Park, MD San Diego, CA
Last Name First Name M.I. Social Security Number Gender Date of Birth
THOMPSON STEVEN L 248-31-4323 ✘ M F 9/22/1962

Street Address Apt No. City State Zip Code Single ✘ Married
48 WESTERN HILLS AVENUE BEDFORD IN 47421

Home Phone Work Phone Work Status

( 812 ) 278-9101 ( 812 ) 553-8015 ✘ Full time Part time
Former last name (if any) Military status Email
Active Retired (date_______) ✘ N/A steven.thompson@argonst.co
m
B. MEDICAL AND DENTAL COVERAGE SELECTIONS - (check all that apply):
Medical Plan (Choose One): Dental Plan:
United Healthcare CHOICE (HMO) Employee Only
✘ United Healthcare PPO ✘ Employee & Spouse

United Healthcare Passive PPO (MI/PA employees only) Employee & Child(ren)
Kaiser (CA employees only) Family
No Coverage Employee & Domestic Partner (“DP”)
Employee & DP + Child(ren)
Coverage Level (Choose One if Electing Coverage): Employee + Child(ren) & DP
Employee Only No Coverage
✘ Employee & Spouse

Employee & Child(ren)

Family
Employee & Domestic Partner (“DP”)
Employee & DP + DP Child(ren)
Employee + Child(ren) & DP
C. DEPENDENT INFORMATION (List all additional members to be covered – use additional sheets if necessary)
Relationship If child is over age 19,
(spouse, DP, please indicate status and/or Other
Last name First Name M.I. Date of Birth child) school Gender Insurance
THOMPSON JOANN E 2/5/1962 spouse Disabled M Yes ✘ Enroll
Student at ______ ✘ F ✘ No Cancel

Disabled Enroll
M Yes
Student at ______ Cancel
F No

Disabled Enroll
M Yes
Student at ______ Cancel
F No

Disabled Enroll
M Yes
Student at ______ Cancel
F No
 Disabled Enroll
M Yes
Student at ______ Cancel
F No

Do any of your dependents live at another address? If yes, complete the following:
Name: Address:

D. OTHER COVERAGE INFORMATION

On the day your coverage begins, will you, your spouse, or any of your dependants be covered under any health plan or policy including
Medicare or Medicaid? Yes ✘ No

Is another person legally responsible for your children? Yes ✘ No

If you answered yes to either of the questions above, please complete the following:
Person’s Name with other Health Plan: Social Security Number:
Date of birth: Gender: M F
Other Company’s Name and Phone Number:
Other Company’s Policy Number and Effective Date:
Medicare Number: Part A Effective Date:
Part B Effective Date:
E. MEDICAL AND DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS
Medical FSA: Dependant Care FSA:
Argon ST will fund this plan with $2,000 for full time employees; You are able to contribute up to $5,000 of pre-tax money for
$1,500 for PT 30 hour employees; $1,000 for PT 20 hour dependant care expenses. You only need to enroll if you wish to
employees. You do not need to make contributions from your own contribute money.
pre-tax dollars to receive the company’s contribution.
Do you wish to participate in the Dependent Care FSA?
Do you wish to contribute to the Medical FSA with your own funds? Yes ✘ No
Yes ✘ No

Employee Pre-tax FSA Contributions: If you wish to contribute, how much money do you want to add for
If you yes, how much do you want to contribute for the 2008 the 2008 calendar year (up to $5,000):
calendar year (up to $3,000):
________ (Employee Contribution Amount)
________ (Employee Contribution Amount)
F. LIFE/AD&D BENEFICIARY DESIGNATIONS (Use additional sheets if necessary)
Life/AD&D Beneficiary Designation:

Primary:
Beneficiary’s Full Name: JOANN ELIZABETH THOMPSON 100% Relationship to Employee: SPOUSE

Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________

Secondary:

Beneficiary’s Full Name JASON PALMER THOMPSON 100% Relationship to Employee: SON

Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________

Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________

Voluntary Life/AD&D Beneficiary Designation (complete only if purchasing Voluntary Life/AD&D coverage):

Primary:

Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________

Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________

Secondary:

Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________

Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________

Beneficiary’s Full Name:_____________________________________________ ____% Relationship to Employee:________________________

Additional enrollment form must be filled out for Voluntary Life/AD&D.

G. AUTHORIZATION (ALL EMPLOYEES – This form must be signed regardless of your coverage elections.)

I understand and agree that any omissions or incorrect statements made on this application may invalidate my and/or my dependents’
coverage. I further understand that coverage will become effective only on the date specified by the Insurer or Plan Administrator, subject
to approval by the Insurer or Plan Administrator and payment of applicable premiums. By signing this form, I hereby certify that all the
information provided is true and correct.

For contributory plans, I understand that by signing this form that I am authorizing the necessary premium deductions from my salary or
wages for the coverage(s) I have selected.

Where applicable to my participation elections above, on behalf of myself and anyone enrolled on this form (“Us”), I authorize any health
care professional or entity to give United HealthCare or Kaiser and related affiliates/designees, any and all records or information
pertaining to medical history or services rendered to Us for any administrative purpose, including evaluation of an application or a claim,
and for any analytical or research purposes. I also authorize on behalf of Us the use of a Social Security Number for purpose of
identification.

NOTICE OF ENROLLMENT RIGHTS:

I understand that if I and/or my dependents, if any, waive coverage and desire to participate in the plan at a later date, coverage may be
subject to treatment as a late enrollee. I further understand that if I decline enrollment for myself or my dependents (including my
spouse) because of other health coverage, I may in the future be able to enroll myself or my dependents in this plan, provided that I
request enrollment within 30 days after such coverage ends. In addition, if a new dependent relationship forms as a result of marriage,
birth, adoption or placement for adoption, I may be able to enroll myself and my dependents provided that I request enrollment within 30
days after such marriage, birth, adoption, or placement for adoption.

X __________________________________________________________________________ __________________________
Signature of Employee Date
H. Kaiser Foundation Health Plan Arbitration Agreement (This must be signed if electing Kaiser coverage)
Kaiser Foundation Health Plan Arbitration Agreement: I understand that (except for Small Claims Court cases, claims subject to a
Medicare appeals procedure, and, if my Group must comply with Employee Retirement Income Security Act regarding certain benefit
related disputes) any dispute
between myself, my heirs, or other associated parties on the one hand and Health Plan, its health care providers, or other associated
parties on the other hand, for alleged violation of any duty arising out of or related to membership in Health Plan, including any claim for
medical or hospital malpractice, for premises liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal
theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law
provides for judicial review of arbitration proceedings. I agree to give up my right to a jury trial and accept the use of binding arbitration. I
understand that the full Arbitration provision is contained in the Evidence of Coverage.

X __________________________________________________________________________ __________________________
Signature of Employee Date
Group Life and Disability Insurance products provided by Unimerica Insurance Company. Medical and Dental Insurance products provided
by United HealthCare Insurance Company and Kaiser.

Enrollment Form Instructions/Checklist

All employees MUST complete and return an enrollment form! Use the checklist below to help you through the
process:

Completed? Item

Section A:
Work Location – Choose One

Employee Information – Complete requested information

Section B:
Choose desired medical coverage – make sure to choose a coverage level if you elect medical
coverage

Choose desired dental coverage (available with our without medical coverage)

Section C:
Enter information about your dependents

Are any of your dependents at a different address?

Section D:
Do you or any of your dependents have other coverage?

Section E:
Enter amount you would like to contribute from your own funds to the Medical Flexible
Spending Account. Note – the ArgonST portion of the account is automatic – you do not have to
enroll to receive this portion. You also do not have to participate in Argon ST medical or dental
coverage to participate in this program. Plan carefully – amounts not used by the end of the
plan year are forfeited by the employee.

Enter the amount you would like to contribute from your own funds to the Dependent Care
Flexible Spending Account.

Section F:
Life and AD&D Beneficiary information – enter the names of your primary beneficiaries. Also,
enter the names of secondary beneficiaries who will receive the proceeds from this program if
your primary beneficiary pre-deceases you.

Voluntary Life and AD&D Beneficiary information – enter only if you are purchasing additional
coverage under Argon ST’s voluntary program.

Section G:
All employees must read and sign the Authorization section.

Section H:
Sign only if you are electing coverage under the Kaiser Permanente program.