All Newly Hired Part Time Faculty Who Have Not Taught for a State of Washington Higher

NOTICE OF POTENTIAL ELIGIBILITY FOR HEALTH INSURANCE AND RETIREMENT BENEFITS

As a part-time faculty member of a public higher education institution of the State of Washington, you may be eligible for State of Washington Public Employee Benefit Board (PEBB) state- sponsored health insurance and the State Board for Community and Technical College (SBCTC) 401a group retirement plan. Eligibility is determined on the following criteria:

All newly hired part time faculty who have not taught for a State of Washington higher education institution are not eligible for PEBB health insurance or SBCTC group retirement annuity 401a retirement plan benefits until they have worked for two consecutive quarters at 50% or more of in class teaching time. To be eligible for the SBCTC 401a group retirement plan, the two consecutive quarters must be earned at a State of Washington Community or Technical College. A part-time faculty member becomes eligible at the beginning of the SECOND consecutive quarter of half-time or more employment at one or more Washington state institutions of higher education for PEBB sponsored health insurance and SBCTC 401a group retirement benefits. Spring and fall quarters are considered consecutive quarters for benefit eligibility. Half-time for credit classes is based on in-class teaching time as defined in Article 6.23 and 6.24 of the faculty negotiated agreement. Half-time or more for non credit in class teaching time is 198 hours per quarter. All part time faculty members will be notified in writing if there is a change in their PEBB eligibility status by the College(s).

It is your responsibility, each quarter, to notify all of the Washington state institutions of higher education at which you are currently employed, in writing, of your multiple employment. If you fail to inform all of your employing institutions of your employment at other institutions during the quarter, you will not be eligible for retroactive benefits.

If you have established eligibility to participate in the State Board for Community and Technical College (SBCTC) group retirement annuity 401a retirement plan with another Washington state community or technical college and are adding employment with Tacoma Community College, or are moving your employment to Tacoma Community College without a break in service, you are eligible to continue SBCTC retirement plan participation at Tacoma Community College. You are required to provide information regarding your established eligibility in the SBCTC 401 group retirement annuity plan, in writing to Tacoma Community College.

You may use the reverse side this form as your notification to Tacoma Community College. Please complete the appropriate information and return this form within 10 days of the start of the academic quarter to:

TCC Human Resources 6501 S 19th Street, Building 18 Tacoma, WA 98466

Employees who are benefits eligible and have a change in their eligibility status will be contacted by their employer(s). Employees have the right to request a re-evaluation of eligibility at any time. It is your responsibility to inform your employer(s) immediately if you are returning from layoff status within 24 months of the layoff date or immediately if you obtain multiple jobs or positions with the employer(s). Upon receipt of this document received with each letter of my faculty appointment(s), I acknowledge that I have the right to appeal the eligibility decision made by my employer(s) through the Public Employee Benefit Board (PEBB) Appeals process. The appeals process and forms are available on the PEBB website at www.pebb.hca.wa.gov

If you have any questions regarding your benefits eligibility, you may contact Leanne Foster at (253) 566-5079 or Janet Carr at (253) 566-5024.

Please complete and return the form to:

TCC Human Resources 6501 S 19th Street, Building 18 Tacoma, WA 98466

EMPLOYEE NAME (please print): TCC System ID Number (if known)

1. Are you currently employed this quarter/semester by other Washington State higher education institutions?

Yes No

Have you been employed as a faculty member by any other Washington State higher education institution during the current academic year (from July 1, 2010 through June 30, 2011)?

Yes No

Have you been employed as a faculty member by any other Washington State higher education institution during the prior two academic years (July 1, 2009 through June 30, 2010 and July 1, 2008 through June 30, 2009)?

Yes No

If yes, please list all the State of Washington higher education institutions:

Two-year averaging: All benefits-eligible faculty (eligible under WAC 182-12-114(3)) who worked an average of half- time or more in each of the two preceding academic years are potentially eligible to receive uninterrupted employer contribution to PEBB benefits. "Academic year" means summer, fall, winter, and spring quarters or summer, fall, and spring semesters and begins with summer quarter/semester. In order to be eligible for the employer contribution through two-year averaging, the faculty must provide written notification of his or her potential eligibility to his or her employing agency or agencies. Receipt of this notice constitutes a written request for two-year averaging consideration. Faculty eligible for the two-year averaging continue to receive uninterrupted employer contribution for each academic year in which they: (i) Are employed on a quarter/semester to quarter/semester basis and work at least two quarters or two semesters; and (ii) Have an average workload of half-time or more for three quarters or two semesters. Eligibility for the employer contribution under two-year averaging ceases immediately if the eligibility criteria is not met or if the eligibility criteria becomes impossible to meet. 2. Are you currently a contributing member of the SBCTC 401a group retirement plan Yes No at other Washington State Community or Technical Colleges?

If yes, please list the State of Washington Community and/or Technical Colleges:

3. Are you a current member or a retiree from one of the State of Washington Department of Retirement Systems (DRS) Public Employees Retirement Systems? Yes No 4. If you are a current member, please check the plan. If you are a retiree from one of the below plans, please check the box and indicate the date of retirement.

PERS 1 PERS 2 PERS 3 TRS 1 TRS 2 TRS 3

Employee Signature: Date: