Opt Out of Insurance Form - Excel

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Opt Out of Insurance Form - Excel Powered By Docstoc
					                                        VALLEY CENTER-PAUMA UNIFIED SCHOOL DISTRICT
                        FRINGE BENEFITS SELECTION SHEET FOR PLAN YEAR January 1, 2011 - December 31, 2011
                                                Completion of this form is required

NAME                                                                   Employee ID #                                           SITE

The District will pay a maximum of $735.00 per pay period, September through June, toward each employee's insurance coverage. Any funds
not spent on insurance will be added to your paycheck (Sept through June), up to a maximum of $300.00 per month. X the box next to the plan
and type of coverage you are electing - 1 each for Medical, Dental, and Vision. The premium will be reflected in the "COST" column of the row,
and the total cost for all selections will be indicated on the "TOTAL COST OF BENEFITS" line. The amount to be deducted - if the total cost
exceeds $735.00 per month, or the amount you will be paid in cafe cash - if the total cost is less than $735.00 per month, will be indicated on
the lower portion of the form.
                                                           CHECK APPROPRIATE BOXES                                                   (payroll use only)
                                                       Employee    Employee     Employee                                           District Vendor #          Chg
                                                          Only     Plus One    Plus Family                         COST
                    PPO 1                               $ 1,084.25  $ 1,764.54   $ 2,539.77

                    PPO 2                               $ 1,031.81         $ 1,678.60          $ 2,415.67                      32293-__________
                    HMO 1 - Full Network                $    790.15        $ 1,282.65          $ 1,843.87                      32028-__________
                    HMO 2 - Value Network               $    723.46        $ 1,173.39          $ 1,686.09                      32290-__________
                    Kaiser                              $    571.34        $ 947.07            $ 1,284.12                      32292-__________
                         I am currently on the Waiver (30/70) from District Medical Coverage and elect to continue this option. I have attached proof of

                    current group Medical insurance and a Waiver of Coverage form. I understand that I must elect District Dental and Vision coverage.
                    Employees on the Waiver may receive the Cafe-Cash benefit up to a maximum of $300 per month on a tenthly basis.

                        I elect to Opt-Out of District Medical Coverage. I have attached proof of current group Medical insurance and a Waiver of
                    Coverage form. I understand I must elect District Dental and Vision coverage and that I will not receive the Café-Cash benefit.
                    *Dependents terminated from the Delta Dental Plan may not be re-enrolled unless they have lost coverage under another group dental plan.
     Delta Dental PPO*                                  $      87.34       $    158.81         $    222.33                     33650-
     DeltaCare PMI                                      $      23.80       $     39.25         $     58.07                     32130-
 VSP VSP Vision Service Plan                            $      11.79       $     24.13         $     33.73                     33550-
District Maximum contribution                                                                                  $    735.00
TOTAL COST OF BENEFITS                                                                                         $       -

If the total cost of benefits exceed $735.00, this amount will be deducted from your check: $                            -     (                  -            )
                                                                                                                                          District Vendor #
** PLEASE NOTE: All medical premiums deducted from your check will be paid before tax unless initialed here

If the total cost of benefits is less than $735.00, this amount to be added to your check, up to maximum $300.00                           $ 300.00 (13-01)

This election form revokes any prior election form completed and will remain in effect. Changes in the cafeteria plan elections can
only be made at the end of the plan year unless due to, and consistent with, a valid status change (e.g. change in legal marital status;
change in number of dependents; termination or commencement of employment; change in work schedule; dependent satisfies or
ceases to satisfy dependent eligibility requirements; changes in residence or worksite) and such other events as would permit a
revocation or change of election under IRC125 regulations. Participation in this plan will automatically cease upon termination of
employment. FICA taxes are not paid on Section 125 salary reduction. Therefore, your social security benefits at retirement may be

I authorize Valley Center-Pauma Unified School District to deduct any balance due from my salary warrant, on a tenthly basis.

Signature (Mandatory)                                                                                                              Date

                    Please return this form and ALL ENROLLMENT FORMS to your SITE OFFICE, by November 9th. 2010.

Description: Opt Out of Insurance Form document sample