Denver Public Schools



4572000-23812500Denver Public Schools2016-2017 Benefits Change FormThis form and supporting documentation must be received within 30 calendar days of Life Event (60 days for Medicaid/CHP+)? Job status change resulting in employee or spouse gaining or losing eligibility for Benefits or change in cost of insurance (ie part time to full time) [Attach supporting documentation] ? Spouse’s employer sponsored healthcare plan(s) during his/ her open enrollment period [Attach supporting documentation] ? Marriage [Attach marriage license and birth certificate for Step Children if applicable] ? Divorce or Legal Separation [Attach copy of final court document]? Birth [Attach copy of birth certificate or hospital issued record] or Adoption (adding dependent(s) through adoption/ guardianship) [Attach copy of court record]? Death of dependent [Attach copy of death certificate] ? Employee or Dependent gains or loses medical coverage under another plan including Medicare, Medicaid or CHP+ [Attach copy of supporting documentation]? Return from DPS unpaid leaveBirth or Adoption is effective the day of the event. All other events are effective the first of the month after receipt of your form if not received by the 10th of the month.1644015635000 Life Change Event Date: Employee NameEmp IDDateAddressCityStateZipMedical PlansEmployee OnlyEmployee + SpouseEmployee + Child(ren)FamilyEmployee OnlyEmployee + SpouseEmployee + Child(ren)FamilyKaiser CDHP3500? $309.12? $726.44? $549.57? $ 948.34DHMP CDHP3500? $332.12? 764.06?$ 535.43?$ 884.31Kaiser CDHP2600? $352.82? $829.12? $636.08? $1,091.22DHMP CDHP2600? $430.61?$ 990.59?$ 712.86?$1,165.16Kaiser CDHP1300? $409.48? $962.29? $748.28? $1,276.51DHMP CDHP1300? $761.26?$1,751.10?$1,307.90?$2,107.38Waive Medical? DentalEmployee OnlyEmployee + SpouseEmployee + Child(ren)FamilyDelta EPO? $28.86? $58.23? $71.32? $100.67Delta PPO? $35.97? $69.06? $97.90? $131.06Waive Dental? VisionVSP Vision?$7.77?$17.30? $17.85? $25.62Waive Vision?Health Savings Account (HSA)You are eligible to enroll in a Health Savings Account only if you are enrolled in one of the four CDHP medical plan offerings. Refer to the DPS Benefits Enrollment Guide for additional restrictions that may apply.Monthly Contribution $____________________ (Employee only: $3,350 annual maximum / Family: $6,750 annual maximum including DPS Contribution) Age 55 and over may contribute an additional $1,000 annuallyHealth Care Flexible Savings AccountDependent Care Flexible Savings AccountMaximum annual election is $2,550/ Minimum monthly election is $20Monthly Contribution $ _______________*You must reenroll during the DPS Annual Open Enrollment period in order to continue this coverage the following plan year.Maximum annual election is $5000 month/ Minimum monthly election is $20 Monthly Contribution $ _______________*You must reenroll during the DPS Annual Open Enrollment period in order to continue this coverage the following plan year.Last Name, First MiddleSS# (Required)RelationshipM FDOB? ?/ /? ?/ /? ?/ /? ?/ /Acceptance and AuthorizationI certify that the information provided is true and complete to the best of my knowledge. I understand that any misrepresentation of information may result in benefit enrollment being voided retroactively to the date in which benefits began. Valid supporting documentation has been/will be provided within the next 3 business days to support any change in benefits that I am requesting. I understand that I can only change from pre-tax to after-tax premium deduction status during annual open enrollment for July 1st effective date. I further understand that it is my responsibility to check my payroll stubs through Employee Self Service to verify that my requested changes are made properly after the effective date of the change (monthly thereafter) and report any discrepancies to HR Connect at 720-423-3900, immediately upon discovery. DPS will not refund premiums in excess of the amount the insurance carrier is willing to reimburse or Flex dollars beyond 2 prior months.Signature: Date: EMAIL: connect_humanresources@ OR MAIL: DPS, 1860 LINCOLN ST., 11th FL., DENVER, CO 80203, ATTN: HR CONNECTAcceptance and AuthorizationEmployee NameEmp IDDateAddressCityStateZipMedical PlansEmployee OnlyEmployee + SpouseEmployee + Child(ren)FamilyEmployee OnlyEmployee + SpouseEmployee + Child(ren)FamilyKaiser CDHP3500? $309.12? $726.44? $549.57? $ 948.34DHMP CDHP3500? $332.12? 764.06?$ 535.43?$ 884.31Kaiser CDHP2600? $352.82? $829.12? $636.08? $1,091.22DHMP CDHP2600? $430.61?$ 990.59?$ 712.86?$1,165.16Kaiser CDHP1300? $409.48? $962.29? $748.28? $1,276.51DHMP CDHP1300? $761.26?$1,751.10?$1,307.90?$2,107.38Waive Medical? DentalEmployee OnlyEmployee + SpouseEmployee + Child(ren)FamilyDelta EPO? $28.86? $58.23? $71.32? $100.67Delta PPO? $35.97? $69.06? $97.90? $131.06Waive Dental? VisionVSP Vision?$7.77?$17.30? $17.85? $25.62Waive Vision?Health Savings Account (HSA)You are eligible to enroll in a Health Savings Account only if you are enrolled in one of the four CDHP medical plan offerings. Refer to the DPS Benefits Enrollment Guide for additional restrictions that may apply.Monthly Contribution $____________________ (Employee only: $3,350 annual maximum / Family: $6,750 annual maximum including DPS Contribution) Age 55 and over may contribute an additional $1,000 annuallyHealth Care Flexible Savings AccountDependent Care Flexible Savings AccountMaximum annual election is $2,550/ Minimum monthly election is $20Monthly Contribution $ _______________*You must reenroll during the DPS Annual Open Enrollment period in order to continue this coverage the following plan year.Maximum annual election is $5000 month/ Minimum monthly election is $20 Monthly Contribution $ _______________*You must reenroll during the DPS Annual Open Enrollment period in order to continue this coverage the following plan year.Last Name, First MiddleSS# (Required)RelationshipM FDOB? ?/ /? ?/ /? ?/ /? ?/ /Acceptance and AuthorizationI certify that the information provided is true and complete to the best of my knowledge. I understand that any misrepresentation of information may result in benefit enrollment being voided retroactively to the date in which benefits began. Valid supporting documentation has been/will be provided within the next 3 business days to support any change in benefits that I am requesting. I understand that I can only change from pre-tax to after-tax premium deduction status during annual open enrollment for July 1st effective date. I further understand that it is my responsibility to check my payroll stubs through Employee Self Service to verify that my requested changes are made properly after the effective date of the change (monthly thereafter) and report any discrepancies to HR Connect at 720-423-3900, immediately upon discovery. DPS will not refund premiums in excess of the amount the insurance carrier is willing to reimburse or Flex dollars beyond 2 prior months.Signature: Date: EMAIL: connect_humanresources@ OR MAIL: DPS, 1860 LINCOLN ST., 11th FL., DENVER, CO 80203, ATTN: HR CONNECTAcceptance and Authorization ................
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