Form Ers Gi 1 180 PDF Details

Form Ers Gi 1 180 is an important form for taxpayers to understand. This form is used to calculate the amount of tax that is owed on income that was earned in a specific year. It can be helpful to use Form Ers Gi 1 180 when preparing your taxes each year. Understanding this form can help you ensure that you are paying the correct amount of tax on your income. Additionally, understanding how this form works can help you plan your finances more effectively for the upcoming year. If you have any questions about Form Ers Gi 1 180, be sure to consult with a qualified tax professional. Thank you for reading!

Form NameForm Ers Gi 1 180
Form Length4 pages
Fillable fields0
Avg. time to fill out1 min
Other namesTexas, ers gi 1 180 form, oO, GBP

Form Preview Example





























Information provided to ERS is maintained for managing your beneits.














If you have questions about your information, or believe that












information provided to ERS may be incorrect, please notify ERS.




















Section A: employee dAtA (For assistance, see the attached instructions.)











Social Security Number/National ID (SSN)



Employee ID







FirstActive Duty Date




































Employee Name:First,MI,Last


Eligibility County





o Check if new





















































ZIP Code



Phone Number


















o Home o Cell (


































Date of Birth














o M

o F


























Agency Name




Dept ID/Agency Number


Employee Class



Insurance Pay Rate







































Employee SSN/National ID Correction



Employee Name Change or Correction


Date of Birth Correction








































Please provide this information, as it could affect the waiting period for your medical insurance.








Were you covered as a dependent under the Texas Employees Group Beneits Program (GBP) at the time of your hire? o Yes o No




If yes, please provide the Social Security number of the person covering you: __________________________________________________

Are you a University of Texas (UT) or Texas A&M University (TAMU) employee or dependent transferring to this GBP-participating agency or institution

without a break in health coverage?

o Yes

o No Date coverage ends ____________











If yes, please provide proof of no break in coverage to your beneits coordinator. If you are a Health and Human Services Enterprise employee, provide

the proof to accessHR.








































Section B: Action (Mark appropriate choice.)




























DTA o FTE to PTE/PTE to FTE OR Retiree RTW/Retiree LTW FSC o Family Status Change

HIR o New Hire LOA o Leave of Absence


PHC o Post Hire Change RED o Reduction while on LOA


REH o Rehire RFL o Return from Leave























Section c: ReASon code (See Family Status Change reference table on page 3 before completing.)






















Complete for changes during the plan year.

Reason Code: _________

Event Date: ________________ (mm-dd-yyyy)






















Section d: inSuRAnce coveRAge (Mark appropriate choices.)










































optional coverage






medical coverage



(Newly hired employees may elect coverage on irst active duty date or within 31 days of hire/rehire without enrolling in medical coverage.)









Effective date, if different from hire/rehire date ______________________ (mm-dd-yyyy)























































Optional Life*

Voluntary AD/D


































Disability *






















































o HealthSelectSM ofTexas


o State ofTexas


o Election I


oYou Only


o Elect


o Elect


o Elect

o HMO Name/City


Dental Choice


o Election 2

oYou + Family












o Election 3










oAdd/Drop Dependent


o HumanaDental


o Election 4




(See Section E)





(See Section E)































oWaive + Opt-Out


oAdd/Drop Depen-
















(By checkingWaive + Opt-Out, you


dent (See Section E)
















also certify that you have comparable





































coverage. See page 4 for important




If you want to elect aTexFlex health or day care account as a new enrollee









or due to a qualifying life event, you must complete the TexFlex Enrollment Change Form.

























*May require evidence of insurability (EOI). EOI form is available at or from your beneits coordinator/accessHR.

Continue to next page to complete form.

ERS GI-1.180 (R 09/2011) (Page 1 of 4)

SSn _______________________________________ employee name: First, mi, last _________________________________________________



Dependent’s Name


Date of

Dependent SSN



Dep. Life





(Required for 12 months or older)









o Sp o D


o M






o S o O


o F



o No

o No

o No









o Sp o D


o M






o S o O


o F



o No

o No

o No









o Sp o D


o M






o S o O


o F



o No

o No

o No









o Sp o D


o M






o S o O


o F



o No

o No

o No









o Sp o D


o M






o S o O


o F



o No

o No

o No









*Relationship Code: Sp – Spouse D or S - Natural or adopted daughter or son O – Other than natural or adopted child. Includes stepchild, foster child, or ward child. If you are adding a child, you must complete a Dependent Child Certiication form (ERS GI 1.081) available at or by calling ERS.

Did your dependent have GBP coverage under ERS through another member within the last 31 days? o Yes o No

If yes, please provide the Social Security number under which your dependent was covered: _________________________________

Is this dependent a new addition to your household because of this event?

Please check one only: oAdoption



oAcquisition of other than natural child

oNot newly acquired

Section F: AuthoRizAtion (Carefully read the statements below before you sign and date.)

I authorize payroll deductions for the elections indicated on this Beneits Election Form. I understand that my insurance coverage may be cancelled if I do not pay the required amounts due, either by payroll deduction or personal payment. I understand that all insurance premiums are deducted on a pre-tax basis, except Dependent Life and Disability. I authorize any provider to release any information on persons covered when needed to verify eligibility or to process an insurance claim/complaint. I understand that insurance participation rules and enrollment and beneits information are available from my beneits coordinator/accessHR or ERS. I understand that double coverage for dependents is not allowed for health and dental coverage in theTexas Employees Group Beneits Program (GBP).

I understand that state law does not permit me to receive more than one state insurance contribution as either an employee, retiree, or dependent. I understand that acceptance of a premium does not constitute valid enrollment of the ineligible person nor waive the eligibility requirements for coverage. I understand that my GBP coverage will remain in effect for the plan year unless I have a qualifying life event (QLE) and that a QLE does not always allow me to make changes to my insurance coverage because the insurance change must be allowable under the GBP rules, AND be consistent with the QLE. notice about insurance - Funding for health and other insurance beneits for participants in the Texas Employees Group Beneits Program (GBP) is subject to change based on available State funding.The Texas Legislature determines the level of funding for such beneits and has no continuing obligation to provide funding for those beneits beyond each iscal year. I understand I may be asked to show documentation to support my selection. False information could lead to expulsion from the GBP and/or criminal prosecution. I certify that all information provided on this form is valid and true to the best of my knowledge.

Employee’s Signature _________________________________________________Date Signed (mm-dd-yyyy) _____________

Keep a copy of this form for your iles and return the original to your beneits coordinator.

If you are a Health and Human Services Enterprise employee, return this form to accessHR

ERS GI-1.180 (R 09/2011) (Page 2 of 4)

Instructions to Complete the Beneits Election Form

1.Complete this form in its entirety. Read the authorization in Section F, sign, and date.

2.Must complete a Dependent Child Certiication form (ERS GI 1.081) available at if you enroll children in coverage.

3.May elect optional coverage without enrolling in health coverage.

This form may be used to:

Enroll in Texas Employees Group Beneits Program (GBP) coverage.

Make allowable changes to GBP coverage or employee data.

Make changes to your National ID, name, date of birth, contact numbers, or mailing address.

New Employees:

May elect health coverage at time of hire; however, this coverage will be effective the irst day of the month following the 90th day of employment.

Employees making changes to their insurance coverage during the plan year:

Use this form to indicate only the changes you want to make.

Complete this form on or within 31 days after your qualifying life event (QLE) (new hire, marriage, etc.).

Using the chart below, identify a reason code (required in Section C) when changing insurance coverage.

Below are examples of qualifying life events; other similar circumstances may also represent a qualifying life event. Contact your beneits coordinator/ accessHR for additional help with your changes.

Family Status Change Reference Chart


Qualifying Life Event (QLE) Example


Employee Marital

Participant gets married




Participant gets a divorce or an annulment


Status Change



Death of a spouse







Birth of a newborn child






Participant adopts, fosters, or gets court-appointed guardianship of child






Participant gains or loses dependent(s) through death






Dependent becomes eligible or loses eligibility for insurance coverage


(Example: Participant’s spouse is covering their child.The child lost eligibility for


Status Change

the spouse’s insurance because the child does not attend school.)








Dependent is related by blood or marriage, and was previously claimed on the participant’s in-



come tax return, but is no longer eligible to be claimed on participants income tax return







Child gets married






Participant/Dependent employment status change


Status Change

Dependent becomes eligible for insurance after a waiting period





Address Change that Changes

Dependent moves out of health or dental plan service area


Dependent Eligibility







Participant/Dependent gains Medicare/Medicaid/CHIP eligibility





Participant/Dependent loses Medicare/Medicaid/CHIP eligibility


Eligibility Change




Signiicant Change

Signiicant change in cost by day care provider


in Cost/Coverage



Signiicant change in cost/coverage of dependent’s health or dental plan (excluding GBP)


Imposed by



HIPP approval or loss of eligibility


Third Party




Court Ordered

Participant gains requirement to provide coverage for child/spouse


(Example: employee receives a medical support order to provide health coverage for his child.)

Coverage Change




Participant requirement to provide coverage for child/spouse expires


(Eligibility rules apply for


(Example: employee’s medical support order to provide health coverage for his child expires and


these dependents)

the employee is no longer required to continue coverage for the child.)







*Employees must contact their beneits coordinator (HHS Enterprise employees contact accessHR) to drop dependent(s) added with an MSO.

Beneit changes must be consistent with the QLE. Dependent eligibility and enrollment rules apply.

You may either enter your changes using your online account at or send this form to your beneits coordinator. If you are a Health and Human Services Enterprise employee, you may send this form to accessHR.

You may be asked to show proof of the QLE or proof of dependent eligibility.

ERS GI-1.180 (R 09/2011) (Page 3 of 4)

Important Information about the

Health Insurance Opt-Out Credit (Section D)

The Health Insurance Opt-Out Credit is designed for employees and retirees who don’t need the State’s health insurance because

they are enrolled in other health insurance that is as good as or better than what the State provides.


• Medicare is not comparable coverage.

If you check “Waive + Opt-Out” on the Beneits Election Form, you agree to the following:

I certify that I do not want the health plan coverage offered to me as an eligible participant. I am waiving my health plan coverage and certify that I have other health plan coverage with substantially equivalent coverage to the basic health plan. I will receive a credit of up to $60 (or $30 for part-time participants) that will be applied only toward the cost of eligible optional coverage (dental andVoluntary AD&D) in which I am enrolled.The credit is in lieu of the state contribution for basic health coverage.

You may contact your beneits coordinator/ACCESSHR for assistance.

If you are a Health and Human Services Enterprise employee, contact ACCESSHR for assistance.

Remember, rules will determine if you can enroll in or make the insurance changes you want.You may notify your beneits coordinator when you move or have a change in family status (qualifying life event), or you may enter the event using your online account at www.ers.state.tx us and make your election changes. If you do not make changes within 31 days, you may not be eligible to make the changes you want.

More information available at:


(877)275-4377 toll-free

ERS GI-1.180 (R 09/2011) (Page 4 of 4)

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Writing segment 1 in Texas

2. Once your current task is complete, take the next step – fill out all of these fields - Section B Action Mark appropriate, Event Date mmddyyyy, Section d inSuRAnce coveRAge Mark, medical coverage, Newly hired employees may elect, Effective date if different from, optional coverage, medical, Dental, Optional Life, Voluntary ADD, Dependent, Life, ShortTerm Disability, and o Waive o HealthSelectSM of Texas with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Texas writing process clarified (step 2)

3. This subsequent section is relatively easy, SSn employee name First mi last, SECTION E DEPENDENT PERSONAL DATA, Dependent, Relationship, Dependents Name, First MI Last, Gender, Date of, Birth mmddyyyy, Dependent SSN, Required for months or older, Health, Dental Dep Life, o Sp o D o S o O, and o Sp o D o S o O - each one of these blanks has to be filled in here.

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Texas conclusion process detailed (portion 4)

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