ࡱ> #` bjbj\.\. >D>D~~~~4v4v4v4h45mb6:^r:r:r:=F?,Alllllll$ohql\E8=^=\E\El~~r:r:mVLVLVL\E~lr:r:lVL\ElVLVL(c,Ter:V6 }v4Fc$hm0mc\rGr0TerTeA2BhVLBTBnAAAllKAAAm\E\E\E\Ev4v4JD,~~~~~~ OPEN ENROLLMENT INSTRUCTIONS Health Insurance Domestic Partnership Please visit the HR web site:  HYPERLINK "http://www.scc-fl.edu/hr/benefits/" http://www.scc-fl.edu/hr/benefits/ and you will see the section for Open Enrollment at the top of the web page. When you select Employees, the list of open enrollment documents, web links, and forms will appear. For your convenience, when you select the forms listed in 1a and 1c below, they will open in Microsoft Word so that you can complete them in Word by using the tab key or the mouse to move through the form (please do not use the enter key). If you would prefer completing a printed form, rather than doing this in Word, forms will be available for you at the Benefits Fairs and in Human Resources. If you are electing health insurance for your domestic partner and/or eligible children, you will need to complete the following forms: Form Election Form for Health Domestic Partnership (this form) Form Affidavit of Domestic Partnership Form Election for Health, Dental, and Life Insurance. You will skip the health section (being replaced by this form) and follow the instructions for completing the dental and life insurance sections of the form. Form Dependent Eligibility - You will need to submit a Dependent Eligibility form if you are covering dependents, other than your spouse or domestic partner, who have a different last name or who will be age 19 or older in calendar year 2008. (If these dependents are included on the Affidavit of Domestic Partnership, you might not need to complete the Dependent Eligibility form. Please ensure that your name and Empl ID are entered on each page that you plan to submit to HR. Once youve reviewed your completed forms, please print them, and sign and date the pages as designated on the forms. Please submit all completed forms to Human Resources by Noon, October 31, 2007. Health Insurance You do not need to complete a health election form if: 1) you want to remain in Plan A, B, C, or D with your same dependents covered or 2) you want to change from Plan E (discontinued plan) to Plan A with the same dependents covered. You must submit a health election form if: 1) you want to change benefit plans (except if changing from discontinued Plan E to Plan A) or 2) you want to add or remove dependents from your health plan. Pre-existing illness limitations may apply for new enrollees who have not been continuously covered by a health insurance plan. You must be enrolled in a college health insurance plan or the Plan C Hospital Indemnity Plan. You must submit the Affidavit of Domestic Partnership with supporting documentation in order to request health coverage for your domestic partner and their eligible dependents. You might also need to submit a Dependent Eligibility form if you are covering dependents, other than your spouse, who have a different last name or who will be age 19 or older in calendar year 2008. HR SERVICES - If you have questions about your benefit elections, please feel free to contact us for additional information. Britt Kintner, Manager Employee Benefits Lynette Cumming, HR Specialist (407) 708-2341 KintnerB@scc-fl.edu (407) 708-2640 CummingL@scc-fl.edu Employee Name  FORMTEXT       Empl ID  FORMTEXT       Health Insurance  Domestic Partnership 1. Please check the box for your election. Health Coverage TypePLAN A PPO Blue OptionsPLAN B BlueCare HMOPLAN D PPO & HRA BlueOptionsBlue Medicare for Spouse enrolled in Medicare BEmployee = EE College-Paid  FORMCHECKBOX  SCC-paid $404  FORMCHECKBOX  SCC-paid $422 FORMCHECKBOX  SCC-paid $390 FORMCHECKBOX  SCC-paid A,B,C, or D Plan rateEE + DP (domestic partner)   FORMCHECKBOX  $337  FORMCHECKBOX  $352 FORMCHECKBOX  $170.86EE + (1-2) Child(ren)/DP Children  FORMCHECKBOX  $235  FORMCHECKBOX  $246EE + (3-4) Children/DP Children  FORMCHECKBOX  $317  FORMCHECKBOX  $331EE + Family   FORMCHECKBOX  $558  FORMCHECKBOX  $584EE + One Dependent  FORMCHECKBOX  $279EE + Two or More Deps  FORMCHECKBOX  $446  Employee Name  FORMTEXT       Empl ID  FORMTEXT       2. If you checked the box in number 1, you may skip this section, otherwise please complete this section on your eligible dependents to be covered in the health plan. Coverage TypeFull NameSocial Security #Date of BirthGenderCheck if DisabledCheck if You Support Check if Lives With YouComplete for Plan B HMO Primary Phys. Name IDSelf  FORMTEXT       FORMTEXT      Dom Part  FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMDROPDOWN   FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMTEXT       FORMTEXT       3. Other Insurance Information.GIgh $ P  < = D ] ^ _ ? 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Policy HolderInsurance Company or MedicarePolicy Number or Medicare NumberEffective Date  FORMTEXT         FORMTEXT         FORMTEXT         FORMTEXT       5. Authorization/Important Reminders I authorize the elections made and any payroll deductions required for such elections. I understand that for covered dependents who have a different last name, or are over age 19, I must submit the Verification of Eligibility for Certain Dependent Children Form with this change form.  FORMCHECKBOX  I am submitting the Affidavit for Domestic Partnership and supporting documentation with this enrollment form. Signature ___________________________________ Date____________     Seminole Community College 2008 OPEN ENROLLMENT BENEFITS ELECTION/CHANGE FORM HEALTH INSURANCE Through the Consortium - BlueCross/Blue Shield of Florida Please complete, sign, date,qqXqqqqqqqXkd<$$Ifl4\@ -l6 xHl 04 laf4 $$Ifa$gdsqqrrrr@rhr $$Ifa$gds $$Ifa$gdxqrr rrrrrr*r,r.r8r:rr@rBrVrXrZrdrfrjrlrrrrfssۼۼۼvgc^YSM hE{CJ h?nCJ h?n5 h:5h 1jh935UmHnHuj>h93h935U h935jh935U h~Rk5&jc>hxhx5CJUaJh~Rk5CJaJ h%5hxhx5CJaJ%jh5CJUaJmHnHu jhxhx5CJUaJ&j=hxhx5CJUaJhrjrlrrytzttt=u?udbYbbbbTbgd:dvL`Lgd:kdW?$$Ifl4\@ -l6 xHl 04 laf4 sssttwtxtytzt{tttttttuu@uAuCuDuFuGuIucuuuuv-CDExvxnxbhH~)h935CJaJh9356>*U h9356 h935 h7Hh935fH`q h935CJhh935CJhzjhzUh4f h:dv5 hsr5 h?n5j@hsrUhsrjhsrU hsrCJ hE{CJ h?nCJhE{h?nCJhE{hE{CJ%?u@uBuCuEuFuHuIuduuuDEڄۄ8UVWÅ$a$gdNp $a$gdco$a$gdtL$a$gd=gdEo$a$gd' and return to Human Resources no later than noon, October 31, 2007 Effective Date of Change: 1/1/2008 Deduction Begin Date: 12/1/2007 /HR/Word/OE2008/ FILENAME Document10  PAGE 1 of  NUMPAGES 4 BAS:_______________PS ENTERED:_______________PROCESS:_______________VERIFIED:_______________  PAGE 3 of  NUMPAGES 4 Please use tab key or mouse; do not use enter key. Please read instructions on pages 1 & 2. Thank you! Please use tab key or mouse; do not use enter key. 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