SONM Welcome Letter Revised 9/5/18

State of New Mexico Welcome Letter

Welcome and congratulations on accepting your new position with the State of New Mexico.

We are glad you have chosen a career in public service and want you to know that your contributions to

the state will have a positive and lasting impact. Public service is inspiring and is one of the most rewarding

of professions. You will have the opportunity to see how this branch of government and your agency’s

mission work together to uphold the three pillars of state government: The Judicial, The Legislative and

The Executive.

We also want to welcome you to your agency; as you become a part of your team, we want you to know

that you are now a part of a tradition of excellence, commitment and service.

The following page contains important information and documentation information you will need to

complete your New Hire Packet. Please review this information and make sure you have correctly

completed each of the forms. Each section of each form should be reviewed for accuracy. This information

is crucial to finalizing your employment with the State of New Mexico.

Again, we welcome you to your new job with the Executive Branch of the State of New Mexico.

The following is information about your new position; this information will help you complete the forms

in your New Hire Packet:

Position Information

Classification:

Status of Position: ☐ Career ☐ Term ☐ Temp Union Status: AFSCME ☐ CWA

Position #: FLSA Status:

PERA Information

Employer:

Salaried Rate $: Hourly Rate $:

Hire Date: Part Time: ☐ Yes ☐ No

PERA Code: Retirement Plan:

To complete the New Hire Packet forms, make sure you also have the following information:

SONM Welcome Letter Revised 9/5/18

Dependent social security number, date of birth, address and phone number

A copy of a voided check or first page of your most recent bank statement

Either one item from List A of the List of Acceptable Documents or a one item from both List B

and List C

If you have any questions about completing or submitting your completed packet, please contact:

Krystal Chavez at (505) 469-7240, email: Krystal.Chavez@state.nm.us or

Vivian Fernandez at (505) 470-7552, email: VivianT.Fernandez@state.nm.us.

For questions regarding your SHARE access or SHARE entry, please contact:

Anna Vigil at (505) 470-9635, email: AnnaM.Vigil1@state.nm.us

It is mandatory that you complete the following paperwork on your first day and have it submitted

to Talent Acquisition on, or before, your third working day.

When completed, please fax the New Hire Packet to Talent Acquisition at (505) 827-5476 or deliver

it in person to:

Talent Acquisition

Joseph Montoya Building

1100 South St. Frances Drive, Suite 3114

Santa Fe, NM 87504

State of New Mexico New Hire Checklist for On boarding

Employee Name: __________ _ Agency Name: ____________ _

Classification: Position#: ------------- ---------------

As a new State of New Mexico (SONM) employee you are required to complete the following f01ms.

Please take the time to thoroughly review and complete each f01m. Doing so will help your new supe1visor

and Talent Acquisition take the steps necessaiy to make your transition into your new position as smooth

as possible. You will find links to the I-9, W-4 and Minnesota. Life Beneficiaiy Designation on the next

page. We have attached the forms in the event you cannot open them from the link. Each

of the remaining documents will follow in the order listed below.

Please fill out the following documents for your personnel file. It is mandato1y that you complete the

pape1work on your first day and have it submitted to Talent Acquisition on, or before, your third

working day. New Hire Documentation □ I-9

□ W-4

□ Securian/Minnesota Life Beneficiai·y Designation*

□ Personal Data

D Acknowledgment of Conditions of Appointment

□ Direct Deposit Authorization

□ PERA Application for PERA Membership*

□ PERA Beneficiaiy Designation*

□ PERA Spousal Consent

D New Hire Benefit Emollment

D HIPP A Notice of Privacy Practices

Acknowledgments D Alternative Dispute Resolution

□ COBRA Notification

D Code of Conduct (Governor's)

D Defensive Driving Course

□ Employee Assistance Program

□ Flexible Spending Account

□ FLSA Status Determination

D Leave/Retirement Infonnation

□ Outside Employment

Disclosure

□ Union Status

□ Workers' Compensation

Please note that for the acknowledgments you only need to send back signature pages. You will keep the

info1mational documents for your reference.

Your Agency specific policies will be emailed to you from the Onboarding Administrator.

Employee Signature: ____________________ Date: ________ _*Requit·es additional dependent infonnation (spouse, domestic partner, child(ren)) such as SSN, DOB and/or address

SONM New Hire Checklist for Onboarding Revised 8/31/18

SONM New Hire Links Revised 9/5/18

State of New Mexico New Hire Links

In addition to the completed hiring packet forms, please fill out the following documents for your

personnel file. It is mandatory that you submit these documents to Talent Acquisition on, or before,

your third working day.

The I-9 form needs to be completed in order to provide the State of New Mexico with proof that you are

eligible to work in the United States. When this form is complete, please have your manager or supervisor

certify it together with your proof of identification. The List of Acceptable Documents can be found at the

end of the documents.

I-9 Form

The W-4 form is required by the IRS in order to make the proper deductions from your paycheck.

Complete sections 1-7 of the form in their entirety, along with the signature and date, for this form to be

accepted. You will need to indicate on the form if you have different Federal and State withholdings.

https://www.irs.gov/pub/irs-pdf/fw4.pdf

The state offers each employee a $50,000 Basic Life policy, at no cost to the employee, when hired. If

you choose, within the first 31 calendar days, to add additional coverage you can do so.

The next form provides beneficiary information to Minnesota Life, the provider, in case the policy has to

be drawn on while still employed with the state. This form requires additional information for your

beneficiaries such as SSN, DOB address and phone number to complete.

https://web1.lifebenefits.com/public/lbwem/83345A_011593_11-2015.pdf

Again, it is mandatory that you submit these documents to Talent Acquisition on, or before, your third

working day. Please submit them along with the rest of your hiring packet to Talent Acquisition at (505)

827-5476 or deliver them in person to: If you have any questions about completing or submitting your

completed packet, please contact:

Krystal Chavez at (505) 469-7240, email: Krystal.Chavez@state.nm.us or

Vivian Fernandez at (505) 470-7552, email: VivianT.Fernandez@state.nm.us.

For questions regarding your SHARE access or SHARE entry, please contact:

Anna Vigil at (505) 470-9635, email: AnnaM.Vigil1@state.nm.us

When completed, please fax the New Hire Packet to Talent Acquisition at (505) 827-5476 or deliver

it in person to:

Talent Acquisition

Joseph Montoya Building

1100 South St. Frances Drive, Suite 3114

Santa Fe, NM 87504

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS Form 1-9

0MB No 1615-0047 Expires 08/3112019

• START HERE: Read Instructions carefully before completing this form. The instructions must be avallable, either In paper or electronically, during completion of this form. Employers are liable for errors In the completlon of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section ~. EmP.19Y8@ I nfqrm@tiQn @nd Att~~~tion {Employees must complete ano sign Section 1 of Form l-9 no later than the fl'!' ~Y. of emptoymen~ t;ut nqt Jjefq_re accepting a Job offer.~

Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt Number City or Town State ZIP Code

Date of Birth (mmlddlyyw) U.S. Social Security Number Employee's E-mail Address Employee's Telephone Number

1111 -m·11111 I am aware that federal law provides for Imprisonment and/or fines for false statements or use of false documents In connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes): ------------------------, D 1. A citizen of the United States

D 2. A noncitizen national of the United States (See instructions) -----------------------------1 D 3. A lawful permanent resident (Alien Registration Number/USCIS Number);

D 4. An alien authorized to work until (expiration dale, ff applicable, mm/dd/yyyy):

Some alfens may write "'NtA· in the expiration date field. (See instructions)

Aliens authorized to worlc must provide only one of the foffowing document numbers to complete Form f-9: QR Code• Section 1

An Alien Registration Number/USCIS Number OR Form /-94 Admission Number OR Foreign Passport Number. Do Not W'ite In ThlS Space

1. Alien Registration Number/USCIS Number:

OR 2. Form 1-94 Admission Number:

OR 3. Foreign Passport Number;

Country of Issuance:

Signature of Employee

PreP41rer. and/or Translatoi: Gertificatjon (~h@~k,Qne):

Today's Date (mmlddlyyyy)

D I did not use a ~rer or.translator. D A ~Jl!lrer(s) aiif/or translator(s) allfsted the employee In comP,letlng ~on 1. (F.ields below must,be completed !_nd !i(Jne<J when preP,Srers ancVoMi8nslators adst an emP.toyee in completing §ectiofi 1.) I attest, under penalty of perjury, that I have assisted In the completion of Section 1 of this form and that to the best of my knowledge the Information Is true and correcl Signature of Preparer or Translator I Today's Date (mmlddlyyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

e Employer Completes Next Page

Fonn 1-9 07/17/ 17 N Page I o fJ

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS Form 1-9

0MB No 1615-0047 Expires 08/31/2019

~ectiont2. Employeri or Authonzea REiP.reientative Review and Verification (EmRlcJyers or their suthiifized ff11?18sentstlve must cgmpfets a!)d -spi s_ectlon 2 viltlifn 3 business days·of tfie emP,li)Y8fl's•fffst gay ofemP.loy,iient, You must physfoafly examfne Ol1!J iJocument from Ust A OR a cpmblnation of one document from U~ Band one doc11ment from Ust C es listed on'lliiJ •usts of Acceptaj,ts Qocuments. j ,,.

I Last Name (Family Name)

Employee Info from Section 1 I First Name (GiVen Name) I M.I. I Citizenship/Immigration Status

List A OR Lista AND LlstC Employment Authorization Identity and Employment Authorization Identity

Document Title Document Title Document Title

Issuing Authority Issuing Authority Issuing Authority

Document Number Document Number Document Number

Expiration Date (if any)(mmlddlyyyy) Expiration Date (if any)(mmlddlyyyy) Expiration Date (if any)(mmlddlyyyy)

Document Title

Issuing Authority Additional Information QR COde • Sections 2 & 3 Oo Not Wile In This Space

Document Number

Expiration Date (if any)(mmlddlyyyy)

Document Title ;1

Issuing Authority

Document Number

Expiration Date (if any)(mmlddlyyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee Is authorized to work In the United States.

The employee's first day of employment (mmlddlyyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative I Today's Date (mmlddlyyyy) I Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative I Ftrst Name of Emp'oyer or Authorized Representative I Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) I City or Town !State IZIP Code

S~¢tiQn 3. Reveiificitlon and Rehires (To be completea iJm:J signed ~Y employer:orautnonzed nipresentative.) A. New Name (If appllcable)

-B. Date of Rehire (if applicable) - -

Last Name (Family Name) I First Name (Given Name) I Middle Initial Date (mmlddlyyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

Document Title I Document Number I Expiration Date (if any) (mmlddlyyyy)

1 attest, under penalty of perjury, that to the best of my knowledge, this employee Is authorized to work In the United States, and If the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the Individual.

Signature of Employer or Authorized Representative Today's Date (mmlddlyyyy) Name of Employer or Authorized Representative

Form 1-9 07/ 17/ 17 N Page 2 of3

1.

2.

3.

4.

5.

6.

LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LISTA LISTB LISTC

Documents that Establish Documents that Establish Documents that Establish Both Identity and Identity Employment Authorization

Employment Authorization QF' AND . U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number

Pennanent Resident Card or Alien State or outlying possession of the card, unless the card includes one of

Registration Receipt Card (Form 1-551) United States provided it contains a the following restrictions: photograph or information such as (1) NOT VALID FOR EMPLOYMENT

Foreign passport that contains a name, date of birth, gender, height, eye

(2) VALID FOR WORK ONLY WITH color, and address temporary 1-551 stamp or temporary INS AUTHORIZATION 1-551 printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH readable immigrant visa govemment agencies or entities, OHS AUTHORIZATION

provided it contains a photograph or Employment Authorization Document information such as name, date of birth, 2. Certification of report of birth issued that contains a photograph (Form gender, height, eye color, and address by the Department of State (Fonns 1-766) DS-1350, FS-545, FS-240)

3. School ID card with a photograph For a nonimmigrant alien authorized 3. Original or certified copy of birth to work for a specific employer 4. Voter's registration card certificate issued by a State, because of his or her status: county, municipal authority, or

5. U.S. Military card or draft record territory of the United States a. Foreign passport; and

b. Form 1-94 or Form l-94A that has 6. Military dependent's ID card bearing an official seal

the following: 7. U.S. Coast Guard Merchant Mariner 4. Native American tribal document

(1) The same name as the passport; Card 5. U.S. Citizen ID Card (Form 1-197) and

8. Native American tribal document (2) An endorsement of the alien's 6. Identification Card for Use of

nonimmigrant status as long as 9. Driver's license issued by a Canadian Resident Citizen in the United that period of endorsement has government authority States (Form 1-179) not yet expired and the

7. Employment authorization proposed employment is not in For persons under age 18 who are conflict with any restrictions or unable to present a document document issued by the limitations identified on the form. listed above: Department of Homeland Security

Passport from the Federated States of Micronesia (FSM) or the Republic of 10. School record or report card

the Marshall Islands (RMI) with Form 11. Clinic, doctor, or hospital record 1-94 or Form I-94A indicating nonimmigrant admission under the 12. Day-care or nursery school record Compact of Free Association Between the United Stales and the FSM or RMI

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M~274).

Refer to the instructions for more information about acceptable receipts.

Fann 1-9 07/17117 N Page 3 of3

Please choose either document from list A or TWO documents from List B and List C

Form W-4 (2019)Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. You may claim exemption from withholding for 2019 if both of the following apply.• For 2018 you had a right to a refund of allfederal income tax withheld because youhad no tax liability, and• For 2019 you expect a refund of allfederal income tax withheld because youexpect to have no tax liability.If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2019 expires February 17, 2020. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General InstructionsIf you aren’t exempt, follow the rest of these instructions to determine the number

using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income not subject to withholding outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2019. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married filing jointly and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. Nonwage income. If you have a large amount of nonwage income not subject to withholding, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Additional Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make .

Specific InstructionsPersonal Allowances WorksheetComplete this worksheet on page 3 first to determine the number of withholding allowances to claim.Line C. Head of household please note: Generally, you may claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.

Line E. Child tax credit. When you file your tax return, you may be eligible to claim a child tax credit for each of your eligible children. To qualify, the child must be under age 17 as of December 31, must be your dependent who lives with you for more than half the year, and must have a valid social security number. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.Line F. Credit for other dependents. When you file your tax return, you may be eligible to claim a credit for other requirement for the child

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate▶ Whether you’re entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20191 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note: If married filing separately, check “Married, but withhold at higher Single rate.”

4 If your last name differs from that shown on your social security card,

check here. You must call 800-772-1213 for a replacement card. ▶

5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . . 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2019, and I certify that I meet both of the following conditions for exemption.

• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)

9 First date of employment

10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2019)

If you are not a new hire and are NOT makingchanges write "NO CHANGES" on this documentbut still complete Name and sign and date

Beneficiary Designation

Securian Financial Group, Inc. Minnesota LIie Insurance Company Securian Life Insurance Company, a New York authorized Insurer 400Robert Street North • St. Paul, Minnesota 55101-2098

Group Customer Service Fax(651)665-4827 SECURIANqp

Visit www.lifebenefits.com to designate your beneficiary.

EMPLOYER NAME: State of New Mexico POLICY NUMBER: 34426

I nsured's name (last, first, middle Initial) ID

Address (street, city, state, zip)

lnsured's date ol birth Policyowner (II different than the Insured) Policyowner's phone number Email address

This beneficiary designation applies to the following coverages for which you are eligible. Use one form for each coverage, If necessary. If this section Is left blank, your designation will apply to all coverages.

0 Alf coverages

0 Basic Life • 34426

0 Additional Employee Life • 34426

INSTRUCTIONS: 1. Clearly print or type the information below.2. Sign and date the completed form.3. Return to Securian at address above.

CHANGE BENEFICIARY REVOKING ALL PRIOR DESIGNATIONS

The primary and contingent beneflclary(les) determines the order In which beneficiaries become eligible to receive a death benefit. Surviving beneficiaries In any category share equally with beneficiaries In the same category unless otherwise specified. Use of the word "Chlldrenn , without modification, lncludes only your biological children of first generation and adopted children. For revocable designations, this signed beneficiary designation, when accepted by the underwriting company, Is the only form needed to elect or change a designation under this pollcy. No other documents are required. Name beneficiaries by category. To receive a death benefit, a beneficiary must survive the insured. In the event a beneficiary does not survive the insured, that beneficiary's portion shall be equally distributed to the remaining beneficiaries within that category. In the event of simultaneous death of the Insured and a beneficiary, the death benefit will be paid as If the insured survived the beneficiary. The same person cannot be named as a primary and a contingent beneficiary.

PRIMARY BENEFICIARY IES) - The oerson or persons named wlll receive the benefit

Beneficiary Full Name Date of

Address and Phone Number Social Security

Relallonshlp Share% (must

Birth Number total 100%)

Total= 100% CONTINGENT BENEFICIARY (JES) - If the primary beneflclary(les) Is no longer living, the benefit Is paid to this person(s)

Beneficiary Full Name Date of

Address and Phone Number Social Security

Relallonshlp Share o/o (must

Birth Number total 100%)

Total= 100%

F83345A 11-2015 ACTLEG

Every classified employee receives 50K of basic life insurance. All employees must complete this form at the time of hire/transfer/promotion

EXAMPLES OF BENEFICIARY DESIGNATIONS

Example 1 : If a primary beneficiary Is to receive the benefit, followed by a contingent beneficiary, If the primary beneficiary Is deceased.

PR - e person or persons name w IMARV BENEFICIARY(IES) Th d Ill h b flt rece vet e ene

Beneficiary Full Name Date of Address and Phone Number Social Security Relationship Share% (must

Birth Number total 100%)

Mary Doe 01·01·1980 123 4th Street, Anywhere, MN 123-'5, 651•665•1234 XXX•XX-XXXX Daughter 100%

Total= 100%

CONTINGENT BENEFICIARY(IES)- If the primary beneflclarv(les) Is no lonaerllvlna, the benefit Is paid to this person(s)

Beneficiary Full Name Date of Address and Phone Number Social Security Relationship Share% (must Birth Number total 100%)

Nancy Doe 02·02·1980 5 Main Street, Anywhere, MN ,seas, 651·665-23-'S xxx-xx-xxxx Sister 100%

Total= 100%

Example 2: If more than one primary beneflclary(les) are to receive the benefit first, followed by the contingent beneflclary(les) If all of the primary beneflclary(les) are deceased.

PRIMARY BENEFICIARY(IES - The person or oersons named wl II receive the benefit

Beneficiary Full Name Date of Address and Phone Number Social Security Relationship Share% (must Birth Number total 100%)

Mary Doe 03·03·1980 123 -'th Street, Anywhere, MN 123-'5, 651·665-3456 xxx-xx-xxxx Daughter -'Oo/o

Jim Doe 04-04-1980 123-'!hStreet, Anywhere, MN 123-'5, 651-665-4567 XXX-XX-XXXX Husband 40%

Mary Smith 05-05-1980 45 Oak S1reet, Anywhere, MN 56789, 651•665•5678 XXX-XX-XXXX Friend 20o/.

Total= 100%

CONTINGENT BENEFICIARYCIES)-lf the primary beneflclarv(les) Is no lonaer llvlna, the benefit Is Paid to this person(s)

Beneficiary Full Name Date of Address and Phone Number Social Security Relationship Share% (must Birth Number total 100%)

Nancy Jones 06·06-1980 s Main Street, Anywhere, MN 45685, 651-665-6789 XXX•XX•XXXX Sister 50%

Jack Williams 07•07-1980 10 Elm Street, Anywhere, MN 58978, 651-665-7890 xxx-xx-xxxx Brother 50%

Example 3: If the beneficiary Is a formal trust. Total= 100%

PRIMARY BENEFICIARYCIES - The Person or persons named will receive the benefit

Beneficiary Full Name Dateof I Address and Phone Number Social Security Relationship Share% (must

Birth Number total 100%)

John Doe • Trustee, his successors or successor in trust under the John Doe Revocable Trust N/A Trust 100% Agreement. Executed by the insured on June 1, 2008.

Total= 100%

State of New Mexico Personal Data Form

BIOGRAPHICAL DETAILS

Effective Date: EMPL ID Social Security Number

First Name MI Last Name

Date Of Birth Birth Country Birth State

Gender Educational Level** Marital Status**

Choose an item Choose an item As of Date:

CONTACT INFORMATION

Address City

State Zip County

Phone Number E-Mail Address

Business: Business:

Home/Cell: Home:

Military Status** Ethnicity**

Choose an item

EMERGENCY CONTACT INFORMATION

Name

Address

Phone Number(s)

Relationship

Employee Signature: ____________________ Date: ________ _

**Voluntary Information : The requested information is volunta ry but is necessary to assure compliance "'i th analysis and repo1·ting requirements of Federal Equal Oppo11unity Laws. Your cooperation is appreciated.

SONM Personal Data Form Revised 8/27 /18

Please complete the entire form. Update any information if you are a transfer/promotion

Ethnicity is not required

State of New Mexico Acknowledgment of Conditions of Appointment

Employee Name: EMPL ID:

Classification: Position #:

Career Appointment

Statement of Willingness to Accept a Career Appointment

IG!l I understand the position I am about to accept is pennanent

• A probationaiy period of one (1) year is required of all employees (This does not apply to pe1manent employees who are transfeITing).

• A probationer may have his/her appointment expired for non-disciplinary reasons with a minimum of 24 hours written notice without right of appeal to the State Personnel Board. Such employees shall be advised in writing if the reason(s) for expiration of appointment.

• The pe1manent status of a probationer begins the day following the end of the probationaiy period.

TERM Appointment

Statement of Willingness to Accept a TERM Appointment IEl I understand the position I ain about to accept is only funded for a specific purpose and/or period of

time. Therefore, upon accepting this position, I will receive a te1m appointment. The te1m appointment is similai· to a probationary appointment, but with the following exceptions:

• The position and the appointment will expire upon loss or reduction of state or federal funding for the project or program or upon its completion. A te1m appointment may be expired with at least 14 calendar day's written notice.

• Expiration of appointment due to tennination of funding or te1mination of a specific project is not appealable to the State Personnel Board.

Temporary Annointment

Statement of Willingness to Accept a T empora1y Appointment IEl I understand the position I ain about to accept is temporary in nature.

• Employment is for less than one (1) year.

• The appointment may be expired with at least a 24 hour written notice, without right of appeal to the State Personnel Board.

• While serving in tempora1y status, any discipline action, including dismissal, may be effective immediately, with written notice and without right of appeal to the State Personnel Boai·d. Such notice shall advise the employee of the action(s) which resulted in the disciplinary action.

Acknowledement

Employee Signature: Date:

SONM Acknowledgment of Conditions of Appointment Revised 8/27 /18

The "Welcome" letter will indicate if your position is Career (Permanent), Term (Special funded), and Temporary (not Permanent position)

State of New Mexico Direct Deposit Enrollment or Change Authorization

Agreement

Employee Name: ____________ _ EMPL ID#: _______ _

Type of action (select one): Cl New Emollment Cl Account Change li:::1I No Change

l!:I DIRECT DEPOSIT Proof of ownership: For the single accotu1t that you own, in whole or in pa11, and to which you iWant I 00% of your net salruy ru1d wages directly deposited, please attach one of the following fotms of documentation. For a checking or savings account, you may attach the first page of the most recent bank statement for the accotu1t showing iYOlll' name on the accotu1t and the accotu1t number, with all financial infonuation (e.g., balances and transactions) redacted. ~ ltematively, for a checking account, you may attach a voided, preprinted check listing you as atl account owner.

Financial Institution Name and Addl'ess

Type

Checldng = C Savings = S

Choose an item.

Authorization and agreement:

Routing Numbel'

(from your financial institution)

Account Numbel'

(employees may haveonly one direct depositaccount)

I authorize the State of New Mexico (State) to directly deposit my net salary and wages to the accollllt designated above and my financial institution to accept such deposits and credit iliem to this accollllt. I Ullderstand and agree iliat:

• 100% of my net salary and wages will be electronically transferred to my financial institution and credited to the accollllt designated above on paydays designated by the State;

• this direct deposit authorization and agreement supersedes and replaces any prior direct deposit auiliorizations and agreements, which I hereby revoke, and will continue in effect lllltil I designate another accollllt or I or the State cancel my enrollment in direct deposit;

• if the State is notified that the accollllt designated above has been closed, I will receive payroll wa1rnnts lllltil I designate a newdirect deposit accollllt;

• the State may, wiiliout liability to me, cancel my enrollment in direct deposit at any time, either temporarily for one or more pay periods or penuanently, in which event I shall receive payroll watl'ants for the affected pay periods;

• in the event that my financial institution does not accept the direct deposit of my net sala1y and wages for any reason, the State has no obligation to process a supplemental salruy and wage payment lllltil my financial institution rettuns the non-accepted payment to the State; and

• I can cancel my enrollment in direct deposit or change my direct deposit accollllt at any time. I Ullderstand and agree that it may take some time for the cancellation or change to take effect, dlll'ing which time my net salary and wages will continue to be directly deposited in the accollllt designated above.

In the event that more money is deposited into my accollllt than is due me, I authorize the State to deduct from the accollllt designated above all amollllts deposited to tile accollllt in en-or and authorize my financial institution to allow such deductions and retum the etl'oneouslypaid amollllts to the State.

EmployeeSignature: __________________ Date: ________ _

[:!I PAYROLL WARRANT (Paper check) Notwithstanding that direct deposit is quicker (i.e., enrolling in direct deposit would mean my net pay would be in my accollllt on payday}, safer (i.e., payroll watl'ants can be lost or stolen), and convenient (i.e., by enrolling in direct deposit, I would not have to cash or deposit a payroll watl'ant or worry about being out of the office on a payday), I decline to participate in the SoNM direct deposit program and hereby revoke any prior direct deposit authorizations and agreements. I Ullderstand that payroll watl'ants will be delivered to my employer on paydays and that I must retrieve the watl'ant from my employer and cash or deposit the watl'ant to have access to my pay.

EmployeeSignature: __________________ Date: ________ _

SONM Direct Deposit EW'ollment or Change Authorization Agreement Revised 9/5/18

In order to process the direct deposit you must attach a "Voided" check or Bank Statement showing ownership of the account.

0 PERA Public Employees Retirement Association of New Mexico

33 Plaza La Prensa, Santa Fe, New Mexico 87507 (505) 476-9401 fax (505) 476-9300 voice

(800) 342-3422 Toll-Free www.nmpera.org

APPLICATION FOR PERA MEMBERSHIP FORM Instructions: Please print or type in dark ink. The original of this form must be completed in its entirety and returned to PERA for processing. Required

fields are in BOLD ITALICS

MEMBER INFORMATION PRINT OR TYPE CLEARLY

SOCIAL SECURITY NUMBER or PERA ID NUMBER

FIRST NAME Ml LAST NAME

MAILING ADDRESS HOME or CELL TELEPHONE NO.

BUSINESS TELEPHONE NO.

CITY STATE ZIP GENDER • MALE • FEMALE

DATE OF BIRTH CITY OF BIRTH STATE OF BIRTH

CURRENT MARITAL STATUS (Check One) la NEVER BEEN MARRIED la MARRIED la DIVORCED IQ] WIDOWED

HAVE YOU EVER BEEN A PERA MEMBER? ~ YES ~ NO EMAIL ADDRESS

ARE YOU OR HAVE YOU EVER BEEN A MEMBER OF THE NM EDUCATIONAL RETIREMENT BOARD? D YES C NO

ARE YOU CURRENTLY RECEIVING A PENSION FROM THE NM EDUCATIONAL RETIREMENT BOARD? D YES • NO

Please use additional Applications for PERA Membership Form(s) if the space on the family information section is not sufficient. Note, however, the designation of a survivor or refund beneficiary is on separate forms. SPOUSE'S NAME SSN DATE OF BIRTH (mm/dd/ccyy)

CHILDREN'S NAME(S) SSN DATE OF BIRTH (mm/dd/ccyy)

MEMBER CERTIFICATION I hereby declare that all the above information is true and complete to the best of my knowledge.

SIGNATURE OF MEMBER DATE

Remember to send corrections to PERA if any of the above information changes. All your PERA records are maintained by using your social security number and PERA ID number. Annual member statements and PERA election ballots are mailed to the most recent address PERA has on fi le for ou. It is our res onsibili to kee our information current.

Please copy the completed application for your employer fi le and for the employee. Mail this original form with the Refund and Survivor Beneficiary Designation Form(s) to PERA immediately upon completion.

NAME OF EMPLOYER PERA EMPLOYER CODE

SALARIED EMPLOYEES ONLY $ ALL OTHER EMPLOYEES, HOURLY RA TE $

DATE EMPLOYED (mmlddlccyy) PART-TIME (20 but less than 30 hours per week) • YES • NO

I certify that the above employee is employed by this PERA affiliate as of the above date.

AUTHORIZED SIGNATURE DA TE (mmldd/ccyy)

TITLE BUSINESS TELEPHONE NO.

September 2015 Employer Certification is completed by Talent Acquisitions.

0 PERA Public Employees Retirement Association of New Mexico

33 Plaza La Prensa, Santa Fe, New Mexico 87507 (505) 476-9401 fax (505) 476-9300 voice

(800) 342-3422 Toll-Free www.nmpera.org

BENEFICIARY DESIGNATION FORM Instructions : Please pr int or type in dark ink. The otiginal of this form must be completed in its entirety and returned to PERA for

processing. Required field s are in BOLD ITALICS

CHECK ONE: IEI New Form IEI Change in Existing Information

MEMBER INFORMATION

SOCIAL SECURITY NUMBER or PERA ID NUMBER

FIRST NAME

MAILING ADDRESS CITY

MARITAL STATUS IC] NEVER BEEN MARRIED

Ml

DATE OF BIRTH (mmlddlccyy)

LAST NAME

STATE ZIP HOME/CELL TELEPHONE NO.

IC] MARRIED DI DIVORCED D WIDOWED

I designate the following person to be my survivor beneficiary to receive a monthly pension payable for life in the event of my death prior to retirement. If I have less than the minimum number of years to meet retirement eligibility when I die, this monthl ension will be a able onl if m death is dut related as rovided b law.

NAME RELATIONSHIP SSN DA TE OF BIRTH ADDRESS/PHONE NUMBER

D Same as above

REFUND BENEFICIARY INFORMATION You May Only Choose One Person Or Organization If no survivor pension is payable, I designate the following person or organization to be my refund beneficiary to receive a refund of my accumulated member contributions. If I do not designate a refund beneficiary, I understand the refund amount will be paid to my estate.

Person NAME RELATIONSHIP SSN DA TE OF BIRTH ADDRESS/PHONE NUMBER

D Same as survivor beneficia

OR Organization ORGANIZATION NAME ADDRESS/PHONE NUMBER TAXID #

SPOUSAL CONSENT

D Check here if you are married and designating someone other than your spouse. If this box is checked , you must submit a separate completed Spousal Consent Form for this designation to be effective.

MEMBER AUTHORIZATION

I hereby declare that all the information provided is true and complete to the best of my knowledge.

SIGNATURE OF MEMBER DATE OF SIGNATURE (mmlddlccyy)

To be completed by a PERA member prior to retirement September 2015

Instructions for Completing the PERA Beneficiary Designation Form

Check the appropriate box at the top of the form if the form is a new designation or a change inexisting information.

Member Information Sectiono Member or employer completes this section. All fields must be complete.

Survivor Beneficiary Information Sectiono Enter the name of the one person to be designated as the survivor beneficiary. PERA

must have the name and birth date of the designated person. PERA stronglyencourages completing the relationship and the social security number of thedesignated person.

Refund Beneficiary Information Sectiono Enter name of the one person to be designated as the refund beneficiary. PERA must

have the name and birth date of the designated person. PERA strongly encouragescompleting the relationship and the social security number of the designated person.

o Or if an organization is designated as a Refund Beneficiary, complete the name,

address and organization tax ID number.

Spousal Consent Sectiono If the member is married and naming someone other than his or her spouse, the

member must complete the Beneficiary Spousal Consent Form. The spouse’ssignature must be notarized and both forms must be submitted to PERA at the sametime for the Beneficiary Designation Form to be valid.

Member Authorization Sectiono The member must sign and date the form.

PERA will accept faxed and scanned copies of this form as long as the member does not need the Beneficiary Spousal Consent Form. If a married member chooses someone other than his or her legal spouse, then PERA must have the original of the Beneficiary Designation Form and the Beneficiary Spousal Consent Form.

This page is informational. Do not send back with your hiring packet.

0 PERA Public Employees Retirement Association of New Mexico

P.O. Box 2123, Santa Fe, New Mexico 87504-2123 (505) 476-9401 fax (505) 476-9300 voice

(800) 342-3422 Toll-Free www.nmpera.org

BENEFICIARY SPOUSAL CONSENT FORM

Instrnctions: Please p1int or type in dark ink. The oliginal of this form must be completed in its entirety and returned to PERA for p rocessing. Required fields are in BOLD ITALICS

MEMBER NAME _________________________ _ First name Last name

MEMBER SOCIAL SECURITY NUMBER or PERA ID NUMBER _________________________ _

SPOUSES INFORMATION AND NOTARIZATION

I, _______________________ , am married to PERA member (print spouse's name)

_______________________ . I hereby consent to my spouse's decision to name (print name of member)

_______________________ as his/her survivor beneficiary and (print name of survivor beneficiary)

_______________________ as his/her refund beneficiary to receive retirement (print name of refund beneficiary)

benefits in the event my spouse dies prior to retirement.

State of

County of _______ )

)

) SS:

Signature of Member's Spouse

Date

Subscribed and sworn to (or affirmed) before me by ________________ on this the ___ day of

(print spouse's name)

My Commission Expires

Notary Signature Notary Public Telephone No:

To be completed by a PERA member prior to retirement March 2015

G:\BEN_INS\ADMIN\EMPLOYEE HANDBOOK Page 1 May2018

Congratulations on your recent employment.

This document contains important information regarding health benefit options that are offered to you as a benefit-eligible employee through the State of New Mexico (SoNM). The document must be read (to its entirety), signed, dated and returned within the first week of employment to the Human Resource Office/SPO - Center of Excellence representing your Agency.

Should you have any questions regarding benefit options, eligibility, form requirements or deadlines, please contact the SoNM’s Third Party Administrator (TPA); Erisa Administrative Services, Inc., at 1-855-618-1800.

CARRIER GROUP

NUMBER CUSTOMER

SERVICELINE WEBSITE

EMPLOYEE ASSISTANCE PROGRAM (EAP) The Solution Group (TSG)

N/A 1-855-231-7737 www.solutionsbiz.com/SONM

PRESBYTERIAN - HMO GR002191 1-888-275-7737 www.phs.org

BCBS OF NEW MEXICO - HMO N66004 1-877-994-2583

www.bcbsnm.com/sonm BCBS OF NEW MEXICO – PPO 266002

EXPRESS SCRIPTS, INC. SONMRXP 1-800-743-1720 www.express-scripts.com

DELTA DENTAL 8523 1-877-395-9420 www.deltadentalnm.com

DAVIS VISION 7468 1-877-923-2847 www.davisvision.com

SONM SHORT/LONG TERM DISABILITY CompuSys/Erisa, Inc.

N/A 1-800-933-7472 mybenefitsnm.com/Disability.htm

SECURIAN/MINNESOTA LIFE 34426 1-855-750-2051 www.LifeBenefits.com

FLEXIBLE SPENDING ACCOUNT (FSA) CompuSys/Erisa, Inc.

N/A 1-800-933-7472 www.nmflex.com

COBRA N/A 855-618-1800 mybenefitsnm.com/Medical.htm

Information regarding the benefits offered through the SoNM, as well as the on-line enrollment form, carrier contact information, etc., can be found at www.mybenefitsnm.com.

EMPOYEE ELIGIBILITY

To be eligible for coverage an employee must be hired as Classified, Exempt, Probationary, Temporary, Term or Hourly and scheduled to work 20 hours or more per week.

DEPENDENT ELIGIBILITY

To be eligible for coverage a dependent must be one of the following: - A lawful spouse or a Domestic Partner (DP);- A biological child, adopted child, step-child (if married to the biological parent), or child of the DP

o Dependent children may be covered up to the end of the month of their 26th birthday

DUE DATES

Enrollment/Waiver Form - new hires must complete the on-line Benefits Enrollment/Waiver Form within 31 calendar days of

hire date. Enrollment must be completed on line. The on-line form must be completed even if employee intends to waive

coverage to all offered benefits. The Benefits Enrollment/Waiver Form can be found at www.mybenefitsnm.com under the Enrollment link located on the Gold Bar, top of page. If enrollment is not received 31 calendar days from the date of hire, enrollment into the benefits program will not be allowed until the next Annual Open enrollment or a qualifying event (see Qualifying Event section on next page). No exceptions will be made.

Proof of Dependency Documents – must also be submitted with-in 31 calendar days of date of hire

State of New Mexico

Benefits Eligibility Acknowledgement

G:\BEN_INS\ADMIN\EMPLOYEE HANDBOOK Page 2 May2018

DEPENDENT ENROLLMENT

It is strongly recommended to fax the proof of dependency documentation to the TPA (505-244-6009) the same day as the on-line enrollment/waiver form is submitted in order to avoid any delays in coverage. If the required documentation is not received within 31 days of the date of hire, the dependent will not be added to coverage. Note: The next opportunity for enrollment would then be with either a Qualifying Event (QE), or at the next annual Open Enrollment.

Proof of dependency documents consist of: marriage certificate, domestic partner affidavit, birth certificate**, court issued placement or adoption papers, or the domestic partner affidavit listing the eligible dependent.

**If a birth certification is not available, please contact the TPA for other possible options.

HEALTH BENEFIT PREMIUM RATES

The Benefits Contribution Schedule can be found at www.mybenefits.nm.us under the Enrollment link located on the Gold Bar, top of page.

Note: Annualized salary is based on a 40-hour workweek, which is used to determine insurance premiums for those hired on an hourly-basis, even if they are scheduled to work less than 40 hours per week.

QUALIFYING EVENTS – Change of Status

If a qualifying event (shown below), is experienced and employee wishes to make changes to elected benefits, these changes must be made using the on-line Benefits Enrollment/Waiver Form. The form, as well as the documentation supporting the qualifying event must be submitted within 31 calendar days of the event.

Change in marital status such as marriage, domestic partnership (DP), divorce/legal separation or termination of DP.Note: Failure to remove the ex-spouse/DP and DP child/ren or step child/ren within 31 days of becoming ineligible may forfeitemployee’s ability to participate in the State’s Benefits Program.

Birth of a child, court approved adoption, placement for adoption, or legal guardianship.

Death of a dependent.

Change in job status of SoNM employee: employment (changing from part-time to full-time or vice versa), reduction in

hours due to FML, LWOP, and/or Disability, or Military Leave.

Change in job status of spouse/domestic partner resulting in loss of group coverage due to termination or gain of othercoverage due to new employment.

Any other circumstance where the employee had outside coverage, then loses this coverage due to circumstancesbeyond their control, eligibility to participate in SoNM’s Benefit Program must be evaluated by the Risk Management Division.

NOTE: Loss of a provider or provider group from carrier coverage is not a qualifying event.

ACKNOWLEDGEMENTS

I understand it is my responsibility to elect and submit coverage for myself and my eligible dependents within 31 days from the date of hire and also understand that if I do not do so within 31 days, the next available opportunity will be either 31 days from a qualifying event, or the next annual Open Enrollment event

I understand it is my responsibility to remove any dependents who do not meet the eligibility requirements, within the 31 days of the dis-qualifying event. Failure to do so may result in my losing the ability to participate in any health benefits offered by the SoNM, as well as full reimbursement of all claims paid out on behalf of the dis-qualified dependent.

I understand it is my responsibility to review my bi-weekly pay advice to ensure deductions are accurate. If deductions are not accurate I must contact the TPA (1-855-618-1800) immediately.

By signing this form employee acknowledges they have read this document in its entirety and understand their responsibilities required to participate in the State of New Mexico’s Benefits Program.

Employee Name/Employee ID# (Print) Employee Signature *Please keep a copy of this form for your records

HR Representative Signature Date

CHECK BOXES before signing

SONM Notice of Privacy Practices Revised 8/27/18

State of New Mexico Notice of Privacy Practices

Many people are worried today about how their personal health information is being used and with very good reason. Information about your health is a very personal thing and its improper use can leave one feeling violated and victimized. The Risk Management Division (RMD) and Erisa Administrative Services, Inc. (Erisa), are equally concerned. This notice details how your medical information may be used and disclosed as well as how you can gain access to this information.

RMD and Erisa are required by federal law to maintain and protect the privacy of your health information and provide you with notice of its legal duties and privacy practices. If you have any questions regarding this notice or the privacy of your health information, please contact RMD/Erisa at PO Box 6850, Santa Fe, NM 87502-0110, or by telephone at 1-855-618-1800.

When Your Health Information Can Be Used or Disclosed By RMD and Erisa Administrative Services, Inc. (Erisa)

RMD and Erisa have always been aware of the sensitivity of protected (or personal) health information (PHI). As such, RMD/Erisa has limited the amount of PHI it receives in its facilities. In addition, RMD/Erisa has ensured that each of its business associates (i.e. health plans) has committed to the same stringent privacy guidelines in dealing with your PHI.

The following categories describe the ways that RMD and Erisa may use and disclose your PHI.

1. Payment Functions – RMD and Erisa may use or disclose your PH to facilitate payment for thetreatment and services you receive. For example, if you send PHI to RMD as part of an appeal ofa health plan decision, RMD may share that PHI with the health plan in order to facilitate thepayment of the charges should they be determined to be covered under your plan.

2. Health Care Operations – RMD and Erisa may use or disclose your PHI in order to conductinsurance- related activities. These activities include, but are not limited to, premium ratings,quality assurance processes (audits), fraud and abuse detection and investigation.

3. Legal Requirements/Law Enforcement – RMD and Erisa may use or disclose your PHI, asrequired by law, in compliance with a court order or subpoena.

4. Public Health/Public Safety - RMD and Erisa may use your PHI to prevent or lessen a seriousand immediate threat to the health or safety of any person or the general public.

5. Health Oversight Activities - Your PHI may be disclosed to health oversight agencies, such asthe New Mexico Department of Insurance (DOI), during the course of audits, investigations,inspections or other proceedings related to the oversight of the health care system.

6. Coroners, Medical Examiners and Funeral Directors – RMS and Erisa may disclose yourPHI to coroners, medical examiners and funeral directors.

SONM Notice of Privacy Practices Revised 8/27/18

7. Organ and Tissue Donation – RMD and Erisa may disclose your PHI to organizations involvedin procuring, banking or transplanting organs and tissues, as necessary.

8. Nation Security – RMD and Erisa may disclose your PHI for military, national security,prisoner, and government benefits purposes.

9. Worker’s Compensation – RMD and Erisa may disclose your PHI, as necessary, to complywith worker’s compensation or similar laws.

10. Marketing – RMD and Erisa may use your PHI in order to contact you about health-relatedbenefits and services that may be of interest to you.

When Your Health Information Cannot Be Used or Disclosed by RMD or Erisa

RMD and Erisa Administrative Services, Inc. (Erisa) may not use or disclose your health information without your written authorization, except as designated above in this notice. If you authorize the use PHI by RMS/Erisa for another purpose, you may revoke your authorization in writing at any time. This revocation, however, cannot undo any disclosures that were already made with your permission.

Your Rights Regarding Your Health Information

1. Right to Request Restrictions – You have the right to request restrictions on the way your PHIis used and disclosed in certain situations. RMD and Erisa are not required to agree to therestrictions but will apply them where prudent and reasonable. If you would like to make arequest for restrictions, you must do so in writing to RMD at PO Box 6850, Santa Fe, NM87502-0110.

2. Right to Request Confidential Communications – You have the right to receive your PHIthrough a reasonable alternative means or at an alternative location for confidentiality purposes.Be sure to include your “alternative location” request in writing to RMD at PO Box 6850, SantaFe, NM 87502-0110. We are not required to agree to all such requests.

3. Right to Inspect and Copy – You have the right to inspect and copy your PHI that may be usedto make decisions about your plan benefits. To inspect and copy such information, you mustsubmit your request in writing to RMD at PO Box 6850, Santa Fe, NM 87502-0110. We maycharge you a reasonable fee to cover expenses associated with your request.

4. Right to Request Amendment – You have the right to request that RMD and Erisa amend yourPHI that you believe is incorrect or incomplete. Upon review, should RMD/Erisa deny yourrequest amendment, you will be provided with information about the denial and how it may beappealed. To request an amendment, please do so in writing to RMD at PO Box 6850, Santa Fe,NM 87502-0110.

5. Right to Know to Whom Your PHI Has Been Disclosed – You have a right to receive a list or“accounting of disclosures” of your PHI, with the exception of disclosures made for paymentfunctions or health care operations. To request this accounting, please submit your request inwriting to RMD at PO Box 6850, Santa Fe, NM 87502-0110.

SONM Notice of Privacy Practices Revised 8/27/18

6. Right to Review This Notice – You have a right to receive a paper copy of this Privacy Noticeat any time. To obtain a paper copy of this Notice, send your written request to in writing toRMD at PO Box 6850, Santa Fe, NM 87502-0110.

Should you wish to discuss these rights in more detail, or if you would like to exercise one or more of these rights, contact RMD/Erisa at PO Box 6850, Santa Fe, NM 87502-0110 or by telephone at 1-855-618-1800.

Changes to this Notice

RMD reserves the right to amend this Notice of Privacy Practices in the future and to make the new Notice effective for all health information that it maintains. RMD will promptly distribute the new Notice to you whenever a material change is made. Until such time, RMD is required by law to comply with the current version of this Notice.

Complaints

Please direct any complaints about this Notice or about hour your PHI is handled, in writing to RMD at PO Box 6850, Santa Fe, NM 87502-0110. RMD assures you that you will not be retaliated against in any way for filing a complaint. If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the Department of Health and Human Services.

************************************************************************************

I, the undersigned, have been provided with Risk Management Division’s (RMD) Privacy Policies and Procedures as well as the Privacy Notice provided to our membership. Both documents have been explained to me and I am in full understanding of their spirit and intent.

Furthermore, I understand the importance of maintaining the privacy of our membership and will do so as provided by RMD’s Policies and Procedures. I recognize that a failure to comply with the policies and procedures may result in disciplinary action as determined by RMD’s Privacy Officer.

Employee Signature: Date:

Employee Printed Name:

CC: Personal File Privacy Officer

SONM Alternative Dispute Resolution Acknowledgment Revised 8/27/18

State of New Mexico Alternative Dispute Resolution Acknowledgment

The Alternative Dispute Resolution (ADR) Office promotes early “In-house” dispute resolution and positive collaboration among state employees, supervisors, managers and agencies through the development and support of effective and efficient programs and policies. The ADR Office coordinates a range of services, to include: a network of skilled mediators to respond to requests for direct assistance; centralized collection of information and resources; consultation on program design; outreach presentations and public education initiatives; skills training; and assistance to other state dispute prevention and resolution efforts.

Mediation Services are provided and is a voluntary and confidential process in which neutral third party mediators help individuals communicate more productively to prevent or resolve problems altogether. Our office coordinates a network of skilled and experienced mediators to respond to requests for direct assistance, as well as forms and guidelines for mediation participants.

For more information, please visit: http://www.generalservices.state.nm.us/riskmanagement/ADR.aspx

Acknowledgment:

Employee Signature: Date:

Employee Printed Name:

CC: Personnel File Enclosure – ADR Information Flyer

SONM COBRA Notification Revised 8/27/18

State of New Mexico COBRA Notification

On April 7, 1986, a federal law was enacted [Public Law 99-272, Title X] requiring that most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of health coverage (called “continuation coverage”) at group rates in certain instances where coverage under the plan would otherwise end. This form is intended to inform you in a summary fashion, of your rights and obligations under the continuation coverage provisions of the new law. Both you and your spouse should take time to read this notice carefully.

If you are an employee of the State of New Mexico covered by Blue Cross Blue Shield, Presbyterian, Delta Dental, or Davis Vision, you have the right to choose continuation of coverage for yourself if you lose group health coverage for any of the following reasons:

• Death of your spouse;• Termination of your spouse’s employment (for reason other than gross misconduct) or reduction

in your spouse’s hours of employment;• Divorce or legal separation from your spouse; or• Your spouse becomes entitled to Medicare.

In the case of a dependent child of an employee covered by any of the above mentioned plans, he or she has the right to continuation of coverage if group health coverage under any of the plans is lost for any of the following five reasons:

• death of a parent;• termination of parent’s employment (for reasons other than gross misconduct) or reduction in a

parent’s hours of employment with the State of New Mexico;• parent’s divorce or legal separation;• parent becomes entitled to Medicare; or• dependent child ceases to be a “dependent child” under the State of New Mexico eligibility rules.

Under the law, the employee or family member has the responsibility to inform the Human Resources Department or your agency group representative with the state of New Mexico if a divorce, legal separation, or child losing dependent status under the State of New Mexico, within 60 days of the date of the event or the date in which coverage would end under the plan because of the event, whichever is later. The State of New Mexico has the responsibility to notify the Plan Administrator of the employee’s death, termination, reduction in hours of employment or Medicare entitlement.

When the Plan Administrator is notified that one of these events has happened, the Plan Administrator will in turn notify you that you have the right to choose continuation coverage. Under the law, you have at least 60 days from the date you would lose coverage because of one of the events described above, or the notice of your election rights is sent to you, whichever is later, to inform the Plan Administrator that you want continuation of coverage.

If you do not elect continuation of coverage, your group health insurance will end.

SONM COBRA Notification Revised 8/27/18

If you choose continuation coverage, the State of New Mexico is required to give you coverage which, as of the time coverage is being provided, is identical to the coverage provided under the plan to similarly situated employees or family members. The new law requires that you be afforded the opportunity to maintain continuation for three (3) years unless you lost group health employment because of termination of employment or a reduction in hours. In that case the required continuation coverage period is 18 months. These 18 months may be extended to 36 months if other events (such as death, divorce, legal separation, or Medicare entitlement) occur during the 18-month period.

For more information, please contact CompuSys/Erisa Group Inc. at (800) 933-7472.

Acknowledgment:

Employee Signature: Date:

Employee Printed Name:

CC: Personnel File

~ • Susana Martinez

GOVERNOR

Paul T. Yarbrough BOARD CHAIRMAN

Ryan Escher BOARDVICE­CHAIRMAN

New Mexico State Personnel Board

State Personnel Office 2600 Cerrillos Road

Santa Fe, New Mexico 87505-0127 (505} 476-7759

General Memorandum 2011-1

Date:

To:

From:

Subject:

April 26, 2011

Cabinet Secretaries, Agency Directors and Human Resources Managers

Eu~~ State Personnel Director

Code of Conduct

Eugene J. Moser DIRECTOR

Nivia Thames DEPUTY DIRECTOR

On April 25, 2011 Governor Susana Martinez issued a Code of Conduct applicable to all employees within the executive service. This Code of Conduct articulates the expectations of the state's officers and employees to maintain an individual commitment to the highest stan<lards of conduct. This is consistent with their roles as public servants of the citizens of the State of New Mexico and with the requirements of the Governmental Conduct Act1 and any other applicable rules or laws governing their conduct, including but not limited to the Financial Disclosure Act2, the Gift Act3 the Lobbyist Regulation Act4 and the Procurement Code5

•

To this end, employees are required at the beginning of each calendar year (January) to acknowledge their receipt, review and understanding of the attached Code of Conduct and copies of the attached statutes referenced abov,e.

1 Chapter 10, Article 16 NMSA 1978 ' Chapter 10, Article 16A NMSA 1978 3 Chapter l 0, Article 16B NMSA 1978 ~ Chapter 2, Article 11 NMSA 1978 •Chapter 13, Article 1 NMSA 1978

The first 2 pages is informational. Do not send back with your hiring packet. Only send Code of Conduct Acknowledgment

Code of Conduct April 26, 2011 Page2

Departments are to ensure that the Code of Conduct is distributed to and acknowledged by all employees on the enclosed classified employee acknowledgement form. This fonn is to be retained within each employee's personnel file within each department. This is expected to be completed by all classified employees no later than May 6, 2011. Departments are requested to coordinate with the Director of the State Personnel Office on ensuring full compliance.

Each department throughout the year shall incorporate within a new employee hire packet the Code of Conduct and obtain an acknowledge receipt which shall be retained in the employee's personnel file.

SONM Defensive Driving Course Acknowledgment Revised 8/27/18

State of New Mexico Defensive Driving Course Acknowledgment

All State of New Mexico employees must successfully complete a 6-hour National Safety Council Certified Defensive Driving Course (DDC) prior to operating any state vehicle for state business.

The Transportation Services Division of the General Services Department conducts the following courses:

• 6-hour DDC for all new state employees.• 4-hour refresher DDC for all state employees who have already taken the 6-hour DDC.

Prior approval must be obtained from your supervisor before attending the DDC. Once approved, please follow agency policy to enroll in the class. You will be notified when enrollment for the classes is confirmed.

For a list of upcoming classes, locations, and online registration, please visit:

www.generalservices.state.nm.us/transportationservices/Defensive_Driving_Training.aspx

www.generalservices.state.nm.us/transportationservices/onlinedefensivedriving.aspx

When you complete the DDC, please submit a copy of your DDC Certificate to the State Personnel Office to place in your personnel file.

Acknowledgment:

Employee Signature: Date:

Employee Printed Name:

CC: Personnel File

SONM Employee Assistance Program Revised 8/27/18

State of New Mexico Employee Assistance Program

The State of New Mexico recognizes that a wide range of problems not directly associated with an employee’s job function can have an effect on an employee’s job performance.

Employees who have a problem which they feel may affect work performance and/or attendance is encouraged to voluntarily seek counseling and information confidentially by contacting the Employee Assistance Program (EAP).

EAP offers up to three (3) free confidential counseling sessions, as well as other services to all employees, eligible dependents and any family members living in the same household. To access your EAP benefits, please call: 1-855-231-7737.

Employees are assured that their job, future, and reputation shall not be jeopardized by utilizing this employee service, although employees participating in the EAP are not exempt from disciplinary action to include dismissal.

For more information, please visit: www.mybenefitsnm.com/EmployeeAssistancePlan.htm

Acknowledgment:

Employee Signature: Date:

Employee Printed Name:

CC: Personnel File

SONM Flexible Spending Account Acknowledgment Revised 8/27/18

State of New Mexico Flexible Spending Account Acknowledgment

A Flexible Spending Account (FSA) is an employer-sponsored benefit that allows you to pay for eligible medical expenses, dependent care, and work-related qualified transportation expenses on a pre-tax basis. If you expect to incur medical expenses that will not be reimbursed by another plan, a FSA is a great way to save money while covering those costs.

The contributions you make to a FSA are deducted from your pay check before your federal, FICA, and state taxes are calculated and never reported to the IRS. The end result is that you decrease your taxable income and increase your spendable income.

You may enroll every year on January 1st, unless you have a qualifying event. You will need to determine an annual election amount to set aside into your FSA. This annual election amount will be deducted from your paycheck in equal installments each pay period and placed in your FSA.

You will receive a benefits debit card to pay for your eligible expenses.

FSA is prefunded, meaning that you will have access to your full annual election amount at the beginning of the plan year regardless of the amount contributed to date. Any funds unused at the end of the year are forfeited.

Qualified transportation benefits also offer pre-tax savings for mass transit/vanpooling and parking expenses incurred when you commute to and from your place of employment.

For more information, please contact CompuSys/Erisa Group Inc. at (800) 933-7472 or visit: www.nmflex.com.

Acknowledgment:

Employee Signature: Date:

Employee Printed Name:

CC: Personnel File Enclosure – FSA Information Flyer

SONM FLSA Status Determination Revised 8/27/18

State of New Mexico FLSA Status Determination

Employee Name: EMPL ID:

Agency: Position #:

The Fair Labor Standards Act establishes minimum wage, overtime pay, recordkeeping, and youth employment standards affecting employees in the private sector and in Federal, State, and local governments. Covered FLSA nonexempt employees receive overtime pay for hours worked over a 40 workweek at a rate not less than one and one-half (1:1.5) times the regular rate of pay. FLSA Exempt employees are paid an established salary and are expected to fulfill the duties of their positions regardless of the hours worked and receive overtime pay for hours worked over 40 per workweek at the employees normal rate of pay.

Effective you accepted the position of

which is .

I with my FLSA determination.

Employee Signature: Date:

SONM Leave/Retirement Information Revised 8/27/18

State of New Mexico Leave/Retirement Information

Employee Name: EMPL ID:

An employee who works 80 hours in a pay period shall accrue leave as indicated below based on service time. An employee who works less than 80 hours in a pay period due to full-time educational leave with pay, absence without leave (AWOL), leave without pay (LWOP), unpaid Family Medical Leave (FML) or is suspended will accrue leave on a pro-rated basis. Leave shall not be used before it is accrued and must be pre-approved according to agency policy.

Years of Service Annual Leave Sick Leave Personal Leave 00-03 years 3.08 hours 3.69 hours *employee’s normal workday 03-07 years 3.69 hours 3.69 hours 07-11 years 4.61 hours 3.69 hours 11-15 years 5.54 hours 3.69 hours 15 years and up 6.15 hours 3.69 hours

*Employees in career status are entitled to one (1) personal leave day each calendar year. The personalleave day will be consistent with the employee’s normal workday. The personal leave day must be takenduring consecutive hours and must be taken by December 31 or it will be lost.

At time of separation, no payment will be made for a personal leave day or accrued sick leave unless the individual is retiring and has more than 600 hours of accrued sick leave. Annual leave shall be paid up to a maximum of 240 hours at the employee’s current base hourly rate.

PUBLIC EMPLOYEES RETIREMENT ASSOCIATION (PERA) CONTRIBUTION RATE

Retirement Plan

Employee Contribution Percentage Employer

Contribution Percentage

Pension Factor per Years of Service Pension Maximum as

a Percentage of the Final Average Salary

Annual Salary less than $20,000

Annual Salary greater than

$20,000 Tier 1 Tier 2

State Plan 3 7.42% 8.92% 16.99% 3.00% 2.50% 90%

RETIREE HEALTHCARE EMPLOYER CONTRIBUTION EMPLOYEE CONTRIBUTION

2% of Gross Earnings 1% of Gross Earnings

Employee Signature: Date:

CC: Personnel File

State of New Mexico Union Status

Employee Name: EMPL ID:

Agency: Position #:

The provisions set forth in the agreements between the State of New Mexico and the American Federation of State, County and Municipal Employee (AFSCME) New Mexico Council 18, effective December 23, 2009, and The Communications Workers of America, AFL-CIO, CLC State Employee Alliance (CWA), effective July 21, 2009, state that bargaining unit eligible employees who have completed their probationary period (one year from hire date) may elect to become a member of the Union and have membership dues deducted from their pay pursuant to Article 10, Deductions, of the current AFSCME agreement and Article 4, Deductions, of the current CWA Agreement. Bargaining unit eligible employees can, if they choose to, contact a Union Representative for membership information.

Furthermore, effective June 27, 2018, the provisions set forth in Article 11, Fair Share, of the AFSCME Agreement and Article 3, Fair Share, of the CWA Agreement are no longer applicable due to the United States Supreme Court ruling, Janus v AFSCME, Council 31. Therefore, the State of New Mexico will no longer withhold “fair share” fees from employees who choose not to participate in union membership. An employee’s sole election to disclaim membership will not adversely affect their employment.

Effective you accepted the position of with (Hire Date) (Job Classification)

(Agency Name)

This position classification IS covered under the CWA or AFSCME CBA (CY or AY)

This position classification IS NOT covered under a CBA for the following reason:

Confidential (CC or AC) Classification not represented (CN or AN) Agency and Classification not represented (NN)

Acknowledgment:

Employee Signature: Date:

SONM Workers’ Compensation Acknowledgment Revised 8/27/18

State of New Mexico Workers’ Compensation Acknowledgment

Any employee injured on-the-job should notify their supervisor immediately and complete a Notice of Accident form through their Supervisor, whether or not the employee requires medical treatment.

If it is an emergency and the employee requires immediate medical treatment, the employee is to go to the nearest emergency facility. All injuries must be reported within 15 consecutive days from the date of injury.

Acknowledgment:

Employee Signature: Date:

Employee Printed Name:

CC: Personnel File

SONM Next Steps and InfoLink Flyer Revised 8/27/18

As you are becoming acquainted with your new position in the State of New Mexico, we invite you to visit InfoLinks, located at http://www.spo.state.nm.us/infolink/default.aspx.

Some of the services available to you through InfoLinks include:

Important contact information for each Center of Excellence Job aids and flow charts for specific process Most requested forms Access to training offered through the State Personnel Office (SPO)

We wish you much success with the State of New Mexico and look forward to working with you.

Sincerely,

Talent Acquisition