VALLEY VIEW COMMUNITY SCHOOL DISTRICT #365-U BENEFIT ELECTION/CHANGE FORM
EMPLOYEE INFORMATION:
Name(LAST, FIRST): , SSN #: - -
Address: City: State: Zip:
Date of Birth: / / Male Female Telephone: ( ) - - Enrollment Reason: New Hire Life Event (Select Below) Open Enrollment EIN#:
Qualifying Live Event: Birth Marriage Spouse Job/Ins Status Change Other (Please Advise):
Date of Hire: Effective Date: Family Status: Single Married
Instructions:
Please complete, sign, date, and return this enrollment form to the Employee Benefits Department no later than 31 days post hire or following a qualifying life event. PLEASE NOTE: Once your enrollment form has been submitted and processed, no changes will be allowed during the current plan year except in the case of a qualifying event. For qualifying life event changes, please provide a copy of documentation confirming the life event.
**Information about your benefits may be obtained from the Insurance Department or visiting VVSD.org**
MEDICAL & DENTAL – BlueCross BlueShield of Illinois (BCBSIL)
PPO MEDICAL PLAN PPO DENTAL PLAN
Employee Employee
Family Employee + 1 (available if you have only one dependent)
*Working Spouse Eligibility Provision – See Reverse Family WAIVER OF COVERAGE
I do NOT elect to participate in the medical plan I do NOT elect to participate in the dental plan
Dependent Information
(You may be required to submit proof of Dependent Eligibility)Extended Dependents – Illinois Law Public Act may allow for continued coverage for your dependents over age 26, if a military veteran. Please contact your Employee Benefits Department to inquire about this option.
Name (LAST, FIRST) Social Security Number Relationship Date of Birth
, - - / / , - - / / , - - / / , - - / / , - - / / , - - / /
VISION - EyeMed
If you are enrolled in the PPO Medical Plan, this benefit is provided to you at no additional cost.
VALLEY VIEW COMMUNITY SCHOOL DISTRICT #365-U BENEFIT ELECTION/CHANGE FORM
PRE-TAX PREMIUM PAYROLL DEDUCTION ELECTION
I agree to have my premium contributions deducted from my paycheck on a pre-tax basis. I understand that my participation and benefits are subject to the terms and conditions of group plan documents and IRS rules. My election will remain the same unless I experience a qualifying event as defined by the IRS or until our next scheduled open enrollment period.
I DO NOT want my premium contributions deducted from my paycheck on a pre-tax basis. (Please Initial)
CONFIRMATION & SIGNATURE
I attest that the information provided above is true and accurate to the best of my knowledge.
I have elected the coverage as designated above and authorize Valley View Community School Dist #365-U to withhold the required amounts from my paycheck. I understand that due to federal regulations, pre-tax elections cannot be changed unless I experience a qualified status change (qualifying event). I understand it is my responsibility to inform Human Resources/Employee Benefits within 31 days of any qualified status changes and to provide updated beneficiary information, if applicable. I further authorize Valley View Community School Dist #365-U to continue these pre-tax and after-tax payroll deductions until such time as I elect to change or stop such elections (if applicable).
Employee Signature Date
* WORKING SPOUSE ELIGIBILITY PROVISION
If your spouse is eligible for health insurance through his/her employer, that spouse is ineligible to enroll on the district’s Health/Vision Plan.
If your spouse is not eligible through their employer or they are self-employed, than your spouse can enroll under the district’s Health/Vision Plan. A signed Working Spouse Affidavit and Working Spouse Inquiry Form are required in addition to the Benefit Election/Change Form.
EMPLOYER USE ONLY Processed With Carriers: Payroll Information:
SCH B SCH A - 5yr PRE -96
Admin F Admin F - 5yr Admin
Transportation & NS
Pre-Tax Premiums Non Pre-Tax Premiums
NOTE:
Any person who with intent to defraud any insurance company or other person files an application for insurance or statements of claim containing any materially false information, or conceals for purpose of misleading information concerning any fact material hereto, commits a fraudulent insurance act, which is a crime, and may also be subject to civil penalties, or denial of insurance benefits.
