2017-2018 Medical Plan Election Form

SCHOOL DISTRICT OF WESTFIELD

N7046 CTY ROAD M WESTFIELD, WI 53964 PH: 608-296-2141  FAX: 608-296-2938

2017-2018 MEDICAL PLAN ELECTION FORM

Employee Name:

I acknowledge that I have been given the opportunity to enroll in the School District of Westfield medical plan and have chosen the following option as indicated below. Additionally, I acknowledge that any contributions required as a result of my elections will be deducted from my paycheck. The new plan year begins July 1, 2017.

I and any covered dependents are electing coverage in the district’s medical plan. The monthly contributions will be:

Single - $93.13 for full time employees (prorated for part time employees) who participate in the bio-metric screening in August 2017 and are not a tobacco/nicotine user Family - $211.03 for full time employees (prorated for part time employees) who participate in the bio-metric screening in August 2017 and are not a tobacco/nicotine user

I elect to waive medical coverage for myself and my dependent(s) offered by the district. I understand that by declining medical coverage, I may not have the opportunity to enroll myself or my dependent(s) on the district’s plan until the next open enrollment period or a special enrollment event (e.g., marriage, birth/adoption of a child, or a qualifying loss of other coverage). I am declining enrollment at this time because:

I/we have other coverage: Spouse’s plan Healthcare Exchange Other (e.g., Medicare, Medicaid, etc.) I/we do not wish to enroll in any coverage at this time.

Signature: ______Date: ______

NOTE: If you are a new enrollment or making changes to your demographics, coordination of benefits or eligible dependents coverage the completion of the full enrollment form is required. Please complete this form by May 31, 2017. Send completed forms to the district office.

If this election form is not received by May 31, 2017, the district will assume that I am electing the same coverage as the 2016-17 plan year.