Board policy allows the employee to continue to participate in the school district’s group health insurance plan until age 65 by meeting the requirements of the insurer.
The licensed employee is responsible for the cost of the health insurance premium. The licensed employee must pay the employee’s share of the premium by paying the monthly premium amount in full to the board secretary prior to the due date of the school district’s premium payment to the insurance carrier.
________ I would like to remain on the school’s health insurance policy. I will submit a check to the Central Office the first of each month. Failure to submit this check will result in loss of insurance coverage.
Plan selected: ___________________________________________________________________
________ I wish NOT to remain on the school’s health insurance policy when I am no longer an ACTIVE employee. (after all pay is received) COBRA option has been explained to me.
________I would like to remain on the school’s dental insurance policy. I will submit a check to the Central Office the first of each month. Failure to submit this check will result in loss of dental insurance coverage. Plan selected: __________________________________________________________
________I wish NOT to remain on the school’s dental insurance policy when I am no longer an ACTIVE employee. (after all pay is received) COBRA option has been explained to me.
________I wish to receive all remaining pay for the _______ school year on June 10, 20__. (Recommend you contact IPERS to discuss, if it is better for you to take all payment in June or to continue to receive checks during July and August. This varies from person to person) If the employee participates in the TaxSaver Plan, the July and August monthly amounts will be deducted from the June 10, 20__ paycheck.
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Licensed Employee Date
