Application to Split Premium

Application to Split Premium
This form requires signatures and is best completed on a device with a touch screen such as a phone, tablet, or touch-screen laptop.

Application to Split Premium
Purpose of this form

This form is to be completed by individuals whose immediate family (Spouse and/or Children) are employed full-time by Legacy Preparatory Charter Academy and wish to split the cost of:
1. Employee and spouse coverage,
2. Employee and children coverage or
3. Employee and family coverage
How Split Premium Works

The employer contributions for all benefit-eligible employees are applied toward a single premium and the remaining premium is split evenly between all employees shown on this form.

Total Wellness Assessment (TWA) Discount

To qualify for the discounted premium, all employees must complete TWA no later than the end of the first month of coverage.

TWA discount will not apply if any employee does not complete the assessment.
I understand the information provided above

What is Required
1. The employee, identified in Section 1, is required to select a Legacy-sponsored healthcare plan.
2. Employee(s), listed in Section 2, is/are required to decline (waive) coverage.
NOTE: The employee(s) identified in Section 2 will be considered as a covered individual for 1095-purposes.
I understand the requirements outlined above

Application to Split Premium
Will you be adding your spouse?
Does your healthcare plan cover more than one dependent who also work full-time for Legacy Preparatory Charter Academy and are benefits eligible?
How many dependents (not including your spouse) are also eligible for benefits as a full-time employee?
Is everyone nearby & available to sign this form?
All employees must be present when completing this form. If an employee is not nearby, do not continue as you will be unable to edit or update your submission.
Does your current healthcare election reflect one employee carrying coverage for all dependents and all others waiving coverage?

Application to Split Premium

Section 1
TO BE COMPLETED BY THE EMPLOYEE covering all dependents.
Employee Name

First NameMiddle InitialLast NameSuffix
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employee ID
As shown in Skyward Employee Access
Legacy Email
example@legacypca.com
By signing below I confirm that I have called the benefit enrollment center & elected coverage for all my dependents shown on this application and elect to split the cost of coverage with my covered dependent(s) who is/are also employed at Legacy Preparatory Charter Academy (Legacy 21, Inc.). I understand that should my dependent’s employment end with Legacy, the employee benefit for the separated dependent will no longer apply and I will remain responsible for the updated monthly premium which will be deducted from my pay. Conversely, should my employment with Legacy end, all coverage will terminate at the end of the month following my last active day and my dependents will be responsible for submitting QLE documentation to re-elect/continue coverage.
Section 1 Employee Signature: (Please sign in the middle of the box)

Application to Split Premium

Section 2
TO BE COMPLETED BY EMPLOYEE(S) that have declined/waived coverage
Spouse Name

First NameMiddle InitialLast NameSuffix
Spouse Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse Employee ID
As shown in Skyward Employee Access
Spouse Email
Only if you would like a copy of this form.
By signing below, I understand my benefits are being carried by the individual shown in section 1 of this form who is also employed with Legacy Preparatory Charter Academy (Legacy21, Inc.). I confirm that I have declined (waived) coverage with the benefits enrollment center at 866-329-2076 and understand I will be covered as a dependent of the employee identified in Section 1. I understand that, should employment with Legacy end, coverage will terminate at the end of the month following their last active day & I will be responsible for submitting QLE documentation to re-elect/continue coverage. Conversely, should my employment end with Legacy, my employee benefit will no longer apply to the then current premiums.
Spouse Signature: (Please sign in the middle of the box)
Dependent 1 Name

First NameMiddle InitialLast NameSuffix
Dependent 1 Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dependent 1 Employee ID
As shown in Skyward Employee Access
Dependent 1 Email
Only if you would like a copy of this form.
By signing below, I understand my benefits are being carried by the individual shown in section 1 of this form who is also employed with Legacy Preparatory Charter Academy (Legacy21, Inc.). I confirm that I have declined (waived) coverage with the benefits enrollment center at 866-329-2076 and understand I will be covered as a dependent of the employee identified in Section 1. I understand that, should employment with Legacy end, coverage will terminate at the end of the month following their last active day & I will be responsible for submitting QLE documentation to re-elect/continue coverage. Conversely, should my employment end with Legacy, my employee benefit will no longer apply to the then current premiums.
Dependent 1 Signature: (Please sign in the middle of the box)
Dependent 2 Name

First NameMiddle InitialLast NameSuffix
Dependent 2 Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dependent 2 Employee ID
As shown in Skyward Employee Access
Dependent 2 Email
Only if you would like a copy of this form.
By signing below, I understand my benefits are being carried by the individual shown in section 1 of this form who is also employed with Legacy Preparatory Charter Academy (Legacy21, Inc.). I confirm that I have declined (waived) coverage with the benefits enrollment center at 866-329-2076 and understand I will be covered as a dependent of the employee identified in Section 1. I understand that, should employment with Legacy end, coverage will terminate at the end of the month following their last active day & I will be responsible for submitting QLE documentation to re-elect/continue coverage. Conversely, should my employment end with Legacy, my employee benefit will no longer apply to the then current premiums.
Dependent 2 Signature: (Please sign in the middle of the box)
Dependent 3 Name

First NameMiddle InitialLast NameSuffix
Dependent 3 Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dependent 3 Employee ID
As shown in Skyward Employee Access
Dependent 3 Email
Only if you would like a copy of this form.
By signing below, I understand my benefits are being carried by the individual shown in section 1 of this form who is also employed with Legacy Preparatory Charter Academy (Legacy21, Inc.). I confirm that I have declined (waived) coverage with the benefits enrollment center at 866-329-2076 and understand I will be covered as a dependent of the employee identified in Section 1. I understand that, should employment with Legacy end, coverage will terminate at the end of the month following their last active day & I will be responsible for submitting QLE documentation to re-elect/continue coverage. Conversely, should my employment end with Legacy, my employee benefit will no longer apply to the then current premiums.
Dependent 3 Signature: (Please sign in the middle of the box)

You cannot complete this form. Please return when everyone is available to sign.
You cannot yet complete this form.

Please call the Benefit Service center at:

866-329-2076

to update your enrollment & return when this has been completed.
This will be your only opportunity to print/save this document.

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