Buffalo City School District Employee Health Insurance Enrollment Form Page 2
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15THE FOLLOWING FORMS ARE REQUIRED TO ESTABLISH YOUR BENEFITS:
Group Life Insurance Enrollment Form (no cost to you)
1.
See attachment for details
Health Insurance Enrollment Form*
2.
Review the enclosed health insurance comparison chart.
Call the Benefits Office to request the Health Insurance Application of your choice.
The application will be processed upon your approval by the Board.
If you are receiving health insurance coverage from another source, you are eligible to participate in
the waiver program, which entitles you to $100 per month in-lieu of health insurance. Contact the Benefits
Office at 816-3754 for a Waiver Program Enrollment Form and details.
*Family health coverage requires:
▪
For Spouse – a copy of page 1 and 2 of your Federal Tax Return (black-out all financial information) or
a copy of your marriage certificate (if married during the current year)
▪
For Dependent Children – copies of birth certificates
Employee Acknowledgement
3.
Information concerning COBRA /HIPAA /Employee Responsibility
DENTAL & VISION BENEFITS - contact the Buffalo Teachers Federation at 881-5400
OPTIONAL BENEFITS
Direct Deposit
A Payroll Form has been included for your convenience.
403(b) Tax Shelter Annuity or NYS Deferred Compensation Account*
Contact company of your choice. See attached listing of approved annuity companies.
Flexible Spending Account* (a tax shelter for unreimbursed medical and dependent care expenses)
Completed application must be returned within thirty (30) days of your hire date or wait for open
enrollment in November.
*For more information please visit our website at Go to Human Resources;
Benefits/Workers Comp.
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