Insurance Costs

2007-08 Insurance Costs
Supervisory/Technical

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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 insurance change/application form, indicating your request.

Fringe Benefit Allocation 2007-08			$910.00
Insurance Type & Provider
MEDICAL
Blue Cross	PPO	Plan B-300
Single Party 2-Party Family	$377.25 $875.85 $1,034.45	$410.75 $940.10 $1,122.05
Kaiser	$5 co-pay	$10 co-pay
Single Party 2-Party Family	$396.40 $792.80 $1,070.28	$374.03 $748.06 $1,009.88
Total MEDICAL COST			$

DENTAL & VISION**
Blue Cross	*BC Plan 1 + vsn**	Willamette DentaCare
Single Party 2-Party Family	$42.60 $89.35 $167.05	$39.85 $80.75 $150.45
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.
**Either dental plan can only be selected with Blue Cross PPO and Kaiser Medical plans.

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 $910 allocation	$

In addition, the District pays the premiums for a $50,000 life insurance policy, Long Term Disability coverage & the Employee Assistance Program. (Not part of the total benefit allocation shown above.)