Insurance Costs

2007-08 Insurance Costs
Administrators

Name __________________________________

Social Security #__________________________

Effective ____________________________, I wish to have the insurance coverage indicated below, with the allocation paid on my behalf, along with my personal funds if needed, through the Employee Insurance Premium Contribution portion of the District's Section 125 Plan.

Reminder: If you have previously waived coverage and are re-enrolling, changing plans or adding/deleting dependents, you will need to fill out an Enrollment Change or New Application Form, indicating your request.

Fringe Benefit Allocation 2007-08			$980.00
Insurance Type & Provider
MEDICAL
Blue Cross	Plan A-100	Plan A-500
Single Party 2-Party Family	$401.15 $918.90 $1,074.85	$367.55 $841.55 $984.65
Kaiser	$5 co-pay	$10 co-pay
Single Party 2-Party Family	$396.40 $792.80 $1,070.28	$374.03 $748.06 $1,009.98
Total MEDICAL COST			$

DENTAL & VISION
Blue Cross	Willamette DentaCare + vsn	BC Plan 1 + vsn
Single Party 2-Party Family	$39.85 $80.75 $150.45	$42.60 $89.35 $167.05
Total DENTAL/VISION COST			$
TOTAL COST of Benefits selected (Enter total on Personal Choice Account Form*)			$

*Enter the amount under "Employee Insurance Premium Contribution" to pre-tax this withholding amount.

CASH OPTION
Waive Coverage	Entire allocation paid as taxable cash (income) *Must be covered by other insurance and a waiver form signed*	$
Balance not needed for health benefits to be paid as taxable cash	Subtract total of medical/dental/vision costs from $980 allocation	$

In addition, the District pays the premiums for a $100,000* life insurance policy, Long Term Disability coverage & the Employee Assistance Program. (Cost is not included in the total benefit allocation show above.)

*The IRS requires life insurance in excess of $50,000 to be taxed on the premium. An adjustment for that tax will be made on your monthly payroll check.