Insurance Benefits Opt-Out TO:

Payroll

Please check one of the following boxes indicating that you are selecting to opt-out of medical insurance benefits or medical, dental and vision insurance benefits offered to eligible employees of Sherwood School District 88J: I wish to opt-out of medical coverage only ($253 monthly cash incentive in 2017-2018). I wish to opt-out of medical, dental and vision coverage ($303 monthly cash incentive in 2017-2018). I understand that by opting-out of this insurance benefit:  The cash incentive will begin the month the form and copy of your valid medical policy card is received, if received by the regular payroll deadline. Payments will not be made retroactively.  The amount of the cash incentive listed above is for the 2017-2018 benefit plan year and is subject to change, or be discontinued in future years.  I must provide the district with proof of enrollment in another group medical insurance policy or medical, dental and vision insurance policies, and continue such insurance coverage while opting out and receiving a cash incentive.  I must notify the district immediately if my other insurance coverage ends. If I do not notify the district within 30 days, I understand I will be subject to repayment of any applicable paid cash incentive.  If my insurance coverage carrier changes or I am requested to provide current proof of enrollment, I will do so upon request.  I am not eligible to re-enroll in the district provided insurance benefits until the next open enrollment period unless I meet the requirements of an OEBB qualifying event.  The district will provide a cash incentive in the amount outlined above based upon my selection. The amount will be added to my regular monthly paycheck as long as I am a benefits eligible employee. For part-time employees, the amount will be pro-rated based on FTE for certified staff and the pro-rated percentages listed in Article 10 of the Collective Bargaining Agreement for classified staff.  If employment is terminated or an employee becomes ineligible for insurance, this agreement is null and void effective that month. I understand that I am still eligible to enroll in dental and vision insurance coverage if I elect to opt-out of medical coverage only, and the district shall provide an Employee Assistance Program at no additional cost. I also understand that the district will pay the cost of long term disability coverage or $10,000 life insurance policy, per collective bargaining agreements, for all employees eligible for insurance benefits. Employee’s Legal Name (please print):

Signature

Date

Please also complete opt out information in OEBB. This form is only valid with a copy of your valid medical insurance policy card.