23-24 Health & Welfare Open Enrollment

Health & Welfare Open Enrollment

23-24 School Year
Email

Confirmation Emailexample@example.com
Employee ID (Last 6 of SS)*
Name
Bargaining Unit
Pay Cycle
FTE
Current Plans
Medical Rate
Medical Plan
Tier
Dental Rate
Dental Plan
Vision Rate
Life Rate
District CAP
Employee Cost
Plan+Tier
Summer-Aug-Sep
23-24 Plan Selections

Effective 10/1/23
Medical Plan Comparison Dental Plan Comparison
Please select one of the following choices:*

Yes, I'd like the same plans as I chose last yearNo, I'd like to choose a different plan beginning October 1stI would like to OPT OUT of all Health & Welfare Benefits for this open enrollment periodI would like to OPT OUT of Medical Benefits only, but would like Dental and Vision Coverage
Bargaining Unit*
If Different from Above
FTE
Pay Cycle
Medical
Medical (RET)
Dental Plan*
Dental Plan (RET)*
Vision*
Dental and Vision Dependents*

Employee OnlySpouseChildrenFamily
Medical Rate
Medical Rate (R)
*Medical Rate includes OPT Out Fee
Dental Rate
Vision Rate
Life Rate
District CAP*
Summer Payback
(June and July 2024)
Employee Cost*
Employee Cost Calc
S125 Unreimbursed Medical and/or Dependent Care
DOES NOT ROLL-OVER
from the previous year and needs to be Enrolled in every year.
Please make an appointment with your American Fidelity Rep to Enroll
Accident and Cancer plans automatically roll over and continue until terminated with American Fidelity
Health Insurance Waiver

I hereby waive my rights to participate in the health insurance coverage offered by Live Oak School District and will provide the district with written proof of coverage. I have comparable coverage under the following Plan:
Insurance Company
Policy or Group #
Primary Member
Who's Plan Are You Covered Under
Comments/Notes
Personal Email*
example@example.com
Date*

MonthDayYear
Date
Please provide personal email address
Signature*

Clear
Should be Empty:

Health & Welfare Open Enrollment

Current Plans

23-24 Plan Selections