Vsp Enrollment Form printable pdf download

VSP Enrollment Form

Please return via school mail to Marj Stolle, OEA by July 15, 2011

VSP Benefits become effective: September 1, 2011

Employee Name:

Employee Social Security #:

School:

Employee Birth Date:

Dependent Names

Dependent

(only list dependents you are enrolling in the vision plan)

Date of Birth

Relationship to Employee

Please check the coverage you are electing.

Employee Only

________ $ 5.10 a month

Employee + Spouse

________ $10.18 a month

Employee + Child(ren) ________ $10.90 a month

Employee + Family

________ $17.42 a month

WAGE DEDUCTION AUTHORIZATION

To: School District of Omaha

Employee Signature: _____________________________ Date: __________________

Pursuant to 79-12, 102 (Nebraska Statutes Revised), the undersigned teacher hereby authorizes and directs the Omaha Public Schools to

withhold from wages to be paid the Annual Deductible Sum determined as provided herein. Annually, the Omaha Education

Association, a professional organization of which the undersigned is a member, will certify to the Omaha Public Schools, the Annual

Deductible Sum which shall be deducted from wage payments. The Annual Deductible Sum shall be deducted rateable from each payroll

check issued by the Omaha Public Schools following receipt of certification of the Annual Deductible Sum for the contract year,

provided however, any portion of the Annual Deductible Sum which remains unpaid shall be deducted from the last payroll check issued

for the contract year. Enrollment in the unified profession shall be on a continuing basis. A member may resign her/his membership in

writing on or before July 1st, for the following year. This authorization shall continue in force until a written notice of revocation

is received by the Omaha Education Association. All amounts deducted shall be sent to the Omaha Education Association. I understand

that the execution of this Wage Deduction Authorization is not required as a condition of membership in the Association.

This authorization shall permit and accept any changes in the amount of dues and/or contributions officially adopted by the respective

governing bodies upon certification of the local association unless I revoke this membership in writing prior to July 1. I affirm that the

above information is accurate to the best of my knowledge. I agree to remit to the Association, on an annual basis the total amount

shown above.

Employee Signature____________________________________________

Date:_________________________________

The following applies only to Section 125 Flexible Benefits Plans: I am signing up for coverage until the next enrollment period

except in the case of a life event. This information was explained in the plan’s solicitation materials which I have read and understand. I

represent that the information I have provided is complete and accurate to the best of my knowledge. The policyholder certifies the date

of employment, job title, hours worked and salary information are correct according to the Policyholder’s records.

Vsp Enrollment Form