DOUGLAS COUNTYSCHOOL DISTRICT #4 and

AMERICAN FIDELITY ASSURANCE COMPANY

SECTION 125 BENEFIT FORM FOR TAXABLE INSURANCE OPT-OUT STIPEND

For All Eligible Staff

SECTION 125 BENEFIT ELECTION

I understand that my employer is allowing the following amount as a taxable benefit under the Section 125 Flexible Benefit Plan.

For Full-Time Administrative & Confidential Staff

$ 444.00 Employer non-elective contribution per month.

Amount will bepaid as taxable income. The District will continue LTD and Life Insurance for eligible staff.

All Eligible Staff

I elect to opt out of medical insurance coverage only, and elect to keep dental & vision coverage. I understand this will reduce the monthly stipend amount by the cost of the vision/dental coverage.

Terms and Conditions

  • I hereby acknowledge I have been offered group coverage under my employer’s insurance carrier and I have opted out of medical and declined dental and vision coverage (unless noted above to continue vision/dental coverage) for myself and eligible dependents. I understand that Iam not eligible for coverage until open enrollment (October 2017).
  • I understand that if I lose other group coverage I will have 30 days to inform my employer and enroll for benefits coverage from OEBB.
  • I hereby acknowledge that I am opting out of my employer’s group coverage because I have other group coverage for medical insurance and agree to provide the other group policy information.

______Other coverage Subscriber name (spouse or partner name)

______Other Carrier ______Employer Name

______Group # ______ID #

  • Participation or enrollment in the Oregon Health Plan/Medicaid, Veteran’s Administration Benefit Programs, Medicare or Student Health Insurance does not qualify for OEBB Opt Out.
  • I agree that I will opt out of medical and decline coverage for dentaland vision on the OEBB website, unless noted above, to keep dental and vision coverage.
  • I acknowledge that if I qualify for early retirement benefits under my employer’s retirement plan, I will enroll for OEBB health, dental and vision coverage during open enrollment of the plan year in which I intend to retire. I further understand that failure to enroll in open enrollment in the plan year of retirement may impact my eligibility in the District’s early retirement program.

This authorization replaces any previous authorization I have made.

Signature of Employee:______

Date: ______