/ 2017Separation Incentive
Election Form
Employee Name: / L#

In accordance with the Memorandum of Agreement (“MOA”) between LCCEF and Lane Community College, you have the option of continuing health insurance for up to twelve (12) months or receiving a lump sum payment of $10,000.00. Additionally, you have the option of continuing access to the Health Clinic for twelve (12) months for you and one eligible dependent 16 years of age or older. Please review the MOA for further information.

Health Insurance Continuation or Lump Sum Payment: Please choose one of the options listed below:

I wish to continue my health insurance coverage for up to twelve (12) months. I acknowledge that the College will continue to make the employer contribution for health insurance premiums for Employee Only coverage. Furthermore, I agree to continue to pay the employee contribution (based upon the 2016-17 rates) during the twelve (12) months in order for the health insurance benefits to continue. I accept that my failure to pay my portion of the health insurance premium will result in the cancellation of my benefits.

I elect to receive a lump sum payment in the amount of $10,000.00 on my payroll check dated. I understand that the lump sum payment is subject to all standard payroll withholding requirements.

Health Clinic Access: Please choose one of the options listed below:

Employee only: I wish to continue my contribution to the Health Clinic for myself for twelve (12) months. As a result, I will continue to be able to access the Health Clinic. I understand that my contribution of $48.00 will be deducted from my last paycheck.

Employee and dependent: I wish to continue my contribution to the Health Clinic for myself and my eligible dependent. As a result, my dependent and I will have access to the Health Clinic. I understand that the contribution for me and my dependent will be $96.00 total and will be deducted from my last paycheck.

Dependent’s Name:

I acknowledge that I have received the option to continue access to the Health Clinic, as outlined in the MOA, and am choosing to decline this benefit.

My separation date from Lane Community College will be:

By signing below, I understand that my notice of separation is irrevocable.

Employee Signature / Date

For questions relating to the insurance and health clinic options
contact Kali Polizzi at (541) 463-5589 or Heidi Morales at (541) 463-5592.

For questions relating to the lump sum payment option
contact Cheryl Volker at (541) 463-5114 or Denine McMurren at (541) 463-5040.