2009 - 10

SIMPSON COLLEGE

MEDICAL INSURANCE PREMIUM REIMBURSEMENT PLAN

MEMORANDUM

  

The College pays $379.84 per month for coverage on each full time employee.  Employees who elect Plan C or the HDHP Plan, which have an individual premium less than $379.84, may elect to have the difference applied to:

·        Employee’s cost of Dental/Vision insurance

·        Employee’s TIAA-CREF Account

·        Refund in June 2010

·        Employee’s HSA (for those with HDHP only)

 

If an employee becomes ineligible for benefits during the policy year, the annual reimbursement will be prorated for the number of months of completed service.

  

I have selected ___ Plan C or  ____ HDHP Employee only coverage.  I wish to have my reimbursement applied as follows:

  

______________________________________________________

(Check all that apply)

 

    ___ I request that my refund be contributed to my dental/vision  
  insurance.

 

     ____  I request that my refund be contributed to my TIAA-CREF retirement
  account.

 

     ____  I request a refund in June 2010.

 

     ____  I request that my refund be contributed to my HSA (for those with
  HDHP only).

 

                                                                              ________________________________
   Employee Signature             Date

 

                                                                             ________________________________
           Print Name