CONFIDENTIAL
(When Filled In)

Name (Last) Woods (First) James (Middle) S.

The following agency-sponsored insurance programs have been explained to me:
- Federal Employees Health Benefits Program (FEHBP)
- Federal Employees Group Life Insurance (FEGLI)
- Federal Employees Dental and Vision Insurance Program (FEDVIP)
- Long Term Care Insurance (FLTCIP)
- Flexible Spending Accounts (FSAFEDS)

I have been given the opportunity to enroll in the above programs and understand that if I do not enroll at this time, I may not be able to enroll until the next open season or until I experience a qualifying life event.

Signature of Employee: James S. Woods
Date: 4/5/2017

I do not elect to participate in any of the stated insurance programs.

Signature of Employee: [Signature]

Employee Interviewed By: [Signature]

INSURANCE QUESTIONNAIRE
CONFIDENTIAL