Saugus

Benefits Forms

CalPERS Health Benefit Plan Enrollment Form HBD-12 - Use this form to make changes, additions or deletetions to your medical insurance plan.             1CalPERSHealthBenefitPlanEnrollmentFormHBD-12.pdf

Medical Eye Services & Delta Dental Enrollment/Change Form - Use this form to add or delete dependents from your dental and vision insurance.  There is no additional cost for full-time employees to add dependents to dental and vision coverage.  2MESandDeltaDentalEnrollmentChangeForm.pdf

Dependent Day Care Reimbursement/Acknowledgement Form - Use this form to submit claims to American Fidelity in order to receive reimbursement from your Dependent Day Care account.  Contact American Fidelity at 800-325-0654 for additional information or questions. 3DependentDayCareReimbursementAcknowledgementForm.pdf 

AFES Section 125 Flexible Benefit Plan Expense Reimbursement - This claim form must be submitted to American Fidelity along w/supporting documentation (see claim form for details) to receive reimbursement from your Unreimbursed Medical Expenses account.  Please contact American Fidelity at 800-325-0654 for additional information or questions. 4AFESSection125FlexibleBenefitPlanExpenseReimbursement.pdf 

Salary Reduction Authorization (SRA) 403B - Complete and submit this form to the Benefits Dept. for new 403b enrollments, vendor changes, increases, decreases or cancellations or your 403b contribution.  If you're interested in plan transfers, withdrawals or loans, please contact our Third Party Administrator, TDS Group at 866-466--1072 and choose option 4.  5SalaryReductionAuthorization-SRA403B.pdf

 

 

Frequently Asked Questions

Am I eligible for benefits? You must work a minimum of 20 hours per week in order to be eligible for benefits. 

• Full-time employees receive $525 per month toward the cost of their medical insurance premium.  In addition, they receive district-paid dental, vision, disability and life insurance benefits.  If a full-time employee waives medical insurance they receive $300 cash in lieu per month (10 times per year). 
•  Part-time employees receive a percentage of the $525 per month towards the cost of their medical insurance premium depending on their percentage of employment.  In addition, the district pays a percentage of dental, vision, disability and life insurance premiums.  If a part-time employee waives medical insurance they receive a percentage of the $300 per month (10 times per year) cash in lieu benefit depending on their percentage of employment.

 What is Open Enrollment and When Does it Take Place? Open Enrollment is the opportunity for benefit-eligible employees to make changes or additions to their benefits package. Open Enrollment takes place during the latter part of the calendar year, between September and November and changes are effective on January 1, 2012.   

 

Can I enroll myself and/or dependents in health coverage outside of Open Enrollment? 

Only if you experience a qualifying event: 

• Marriage - You must add your spouse within 60 days of the date of marriage and submit a copy of your marriage certificate with your enrollment forms .  The coverage for your spouse will take effect the first of the month following the date you submit the paperwork to the Benefits Department. 
•  Birth of a child –Your child will be covered under your insurance for the month of their birth. Please submit the enrollment forms  along with a copy of the hospital birth certificate as soon as possible. The coverage for your child will take effect the first of the month following the date of the child’s birth.
• Loss of coverage - If either yourself or a dependent lose coverage you can enroll outside of open enrollment as long as you complete the enrollment forms  and submit proof of loss of coverage.  The coverage will take effect the first of the month following the date you submit the paperwork to the Benefits Department.

Can I drop health coverage for myself and/or dependents outside of Open Enrollment? 

Yes, in some cases.  For example, you may drop your spouse in the event of a divorce, but must submit a change form and a copy of the divorce decree.  Your spouse’s coverage will end the first of the month following the date you submit the paperwork to the Benefits Department.  You may drop coverage for yourself if you obtain other coverage but you must submit a change form and proof that you have other coverage.  Your coverage will end the first of the month following the date you submit the paperwork to the Benefits Department.

How long can my children stay on my insurance benefits?

Dependents may be covered on your medical, dental and vision plans until their 26th birthday. 

How do I have my medical premium deducted on a pre-tax basis?

When you enroll for medical insurance coverage, your deduction is automatically taken out on an after-tax basis.  If you would like to have it taken out on a pre-tax basis, which saves you money, you need to make an appointment with our American Fidelity representative.  This change can be made during Open Enrollment or upon hire.

Are there optional benefits available to SUSD employees?

Yes, American Fidelity offers additional life, cancer and accident insurance plans, and Prudential offers a voluntary Accidental Death and Dismemberment plan. 

What is a Flexible Spending Account?

A Flexible Spending Account (FSA) utilizes pre-tax dollars to save on medical expenses and dependent day care expenses throughout the year.  American Fidelity offers two types of Flexible Spending Account programs which you can sign-up for during Open Enrollment each fall. 

• The first is an FSA for un-reimbursed medical expenses.  With this account, you may elect to have up to $4800 deducted pre-tax from your paycheck annually.  You would then submit a claim form to American Fidelity for medical, dental or vision expenses that you’ve paid for out of pocket. 
• The second FSA is for dependent day care expenses.  With this account, you may elect to have up to $5000 deducted pre-tax from your paycheck annually.  You then submit a claim form to American Fidelity for your daycare expenses. 

What is a 403b and how do I sign up for one?

A 403b is a Tax Sheltered Annuity (TSA) that allows you to save for retirement using tax deferred dollars.  The maximum annual contribution amount for 2011 is $16,500.  If you are over 50 you may contribute an additional $5,500.  For a list of participating vendors go to www.403bcompare.com.  You will need to work with your broker or financial planner to set up your account with one of the approved vendors.  When your account has been established, complete a Salary Reduction Agreement form and submit it to the Benefits Department to set up your payroll deduction. 

How do I make a change to my 403b deduction?

You may cancel, make a change to your deduction amount or change vendors at any time.  Simply complete a new Salary Reduction Agreement form and submit it to the Benefits Department.

How do I request a transfer or a loan from my 403b?

Any 403b transaction that requires an employer signature must be reviewed and approved by TDS group, our third party administrator.  TDS group can be contacted at 866-446-1072.