1. Healthcare

Ankeny Community Schools Insurance Elec on Form - Fiscal Year 2014-2015
PLAN YEAR: JULY 1, 2014 - JUNE 30, 2015 DUE DATE: MAY 1, 2014
Employee Number _______________________
Building ______________________________
Printed Name _______________________________________________
Insurance plan summary informa on can be found on the District website in the Staff Intranet under: Departments >>
Human Resources >> 2014-2015 Annual Enrollment.
Insurance Elec ons:
Group Health Insurance - UnitedHealthcare of the River Valley:
_____ Not Eligible (Cer fied Staff working less than 20 hours per week or less than .5 FTE; All other staff working
less than 30 hours per week)
_____ Waiving (If eligible and elec ng not to enroll, proof of other coverage must be provided with this elec on form)
_____ Single Blue Plan
_____ Pre-Tax _____ A er-Tax
_____ Family Blue Plan
_____ Pre-Tax _____ A er-Tax
_____ Single High Deduc ble Plan
_____ Pre-Tax _____ A er-Tax
_____ Family High Deduc ble Plan
_____ Pre-Tax _____ A er-Tax
The HDHP (High Deduc ble Health Plan) is only available to Administra ve and Confiden al Staff.
Group Dental Insurance - Delta Dental of Iowa Premier & PPO Networks:
_____ Not Eligible (Support Staff; Confiden al Staff working less than 30 hours per week; Cer fied Staff working less than .5 FTE)
______ Waiving (If eligible and elect not to enroll, proof of other coverage must be provided with this elec on form)
_____ Single Dental
_____ Pre-Tax _____ A er-Tax
_____ Family Dental
_____ Pre-Tax _____ A er-Tax
Voluntary Benefits
Avesis Vision/Epic Hearing:
_____ Single
_____ Pre-Tax _____ A er-Tax
_____ Single+1
_____ Pre-Tax _____ A er-Tax
_____ Family
_____ Pre-Tax _____ A er-Tax
_____ Declining Coverage
Colonial Life: Cancer Insurance; Accident Insurance; Universal Life Insurance
Rates will vary. To enroll contact Al Harris @ 515-252-7099 or 515-491-6229. Colonial will confirm enrollment and
employee cost with Human Resources and Payroll. Employees will be noƟfied prior to any pay deducƟon.
AFLAC: Cancer Insurance; Cri cal Illness; Hospital Protec on; Accident Indemnity
Rates will vary. To enroll contact Jerri Gregory @ 515-779-3593; or [email protected]. AFLAC will confirm
enrollment and employee cost with Human Resources and Payroll. Employees will be noƟfied prior to any pay
deducƟon.
Listed contact is subject to change; updates will be provided.
If you have elected the pre-tax method of payment for insurance premiums, you have elected a salary reduc on which reduces your wages for social security purposes, and may reduce your social security disability and re rement benefits. This account will not pay you interest. Once you make this elec on or if you have
declined to par cipate, changes can only be made at the beginning of the next plan year or if there has been a qualified life event.
Signed ____________________________________________
Date Signed ___________________________________
Revised 4/4/14 LD
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