GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRICT PART-TIME (NON-FACULTY) HOURLY HIRING CHECKLIST All necessary paperwork must be completed BEFORE an employee begins work. Notification from HUMAN RESOURCES that the employee is authorized to work is required. If you have questions, please contact HUMAN RESOURCES, x7644. Applicants receive a hire packet from the department intending to employ them and consists of the following: HIRE/REHIRE/CHANGE FORM - DEPARTMENT MUST OBTAIN APPROPRIATE HIRE FORM FROM “FORMS DEPOT” I-9 - EMPLOYMENT ELIGIBILITY VERIFICATION. HIRING SUPERVISOR/MANAGER MUST COMPLETE SECTION #2 AND COPIES OF DOCUMENTS PRESENTED TO VERIFY THE I-9 MUST BE SUBMITTED WITH THE I-9 AND HIRE PACKET. SUPPLEMENTAL QUESTIONNAIRE FORM EMPLOYEE INFORMATION FORM TAX FORM(S) - W-4/FEDERAL, DE4/STATE GCCCD COMPUTER SYSTEM SECURITY AND USE STATEMENT OATH OF ALLEGIANCE STATEMENT OF EMPLOYMENT NOT COVERED BY SOCIAL SECURITY NOTICE OF EXCLUSION FROM CALPERS MEMBERSHIP (PERS-AESD-139) PERS SELF-CERTIFICATION FORM (PERS-CASD-801) VERIFICATION OF MEMBERSHIP IN RETIREMENT SYSTEM DIRECT DEPOSIT INFORMATION DIRECT DEPOSIT FORM (MANDATORY) EMPLOYEE’S DESIGNATION OF BENEFICIARY RECEIPT OF WORKER’S COMPENSATION INFORMATION YORK INFORMATION WELLCOMP MPN PRE-DESIGNATION OF PERSONAL PHYSICIAN (OPTIONAL) SAFETY TIPS/RIGHT TO KNOW ACKNOWLEDGEMENT SAFETY TIP/RIGHT TO KNOW BOOKLET FBC 3121 INFORMATION 3121 BENEFICIARY DESIGNATION FORM (EXCEPT FOR FT GCCCD WORK-STUDY AND FT GCCCD STUDENT EMPLOYEES) DISTRICT DRUG FREE-WORK PLACE POLICY PAYROLL INFORMATION FOR HOURLY EMPLOYEES FAQ HEALTH INSURANCE MARKETPLACE MARKETPLACE NOTICE NOTICE OF HEALTHY WORKPLACE HEALTHY FAMILY ACT OF 2014 PAID SICK LEAVE (AB1522) LIVE SCAN (IF REQUIRED) (MUST BE SUBMITTED USING DISTRICT TB TEST (IF REQUIRED) “REQUEST FOR LIVE SCAN SERVICE” FORM Before signing the Hire/Rehire/Change form, the supervisor must review all information/forms to ensure that all is completed accurately and legibly. It is the supervisor’s responsibility to review the Safety tips/Right to Know booklet for all new employees. All completed hire forms are to be stapled together and routed through manager offices then forwarded to Human Resources. 1. 2. Short-term Employment a. Substitute employee i. Classified Employee Absence 1. Replacing the temporary absence of a permanent classified employee on an approved leave of absence 2. Appointment may not exceed 175 days in an academic year. Work for any portion of a day constitutes a day. 3. Must pass a Live Scan background check and TB test ii. Vacancy Replacement 1. Filling a vacancy of a permanent classified position 2. The district is actively engaged in the recruitment process (approved for recruitment and on the critical hire list) 3. Appointment period may not exceed 60 calendar days, subject to extension by mutual agreement between CSEA and the District per the CSEA collective bargaining agreement. 4. Must pass a Live Scan background check and TB test b. Short-Term Hourly Employees i. Performing a service, upon the completion of which, the service required or similar services will not be extended or needed on a continuing basis ii. Appointment may not exceed 175 days of an academic year. Work for any portion of a day constitutes a day. iii. Must pass a Live Scan background check and TB test iv. Not eligible to work more than a cumulative total of 40 hours per week unless it is approved in advance and in writing by the appropriate manager and VP/AVC v. Cannot supplant classified work Student Workers a. Federal or State Funded College Work-Study or Work-Experience Programs i. Must be part of a work-study or work experience program ii. Must complete the federal/state Student Aid Application and it must be awarded to the student under federal/state methodology iii. Must be enrolled in at least 6 units (part-time or full-time) iv. Live Scan background checks and TB tests may be required by specific programs (e.g. Child Development Center) v. Must work fewer than 40 hours during any workweek vi. Must maintain satisfactory academic progress according to federal/state guidelines b. 3. 4. All Other Student Workers i. Must be a student at GCCCD or other accredited College or University ii. Must be full-time (12 units or as defined by academic program in which the student is enrolled) 1. Students working in the summer must have been full-time in the prior fall or spring semester or be a full-time student during the summer semester (6 units or as defined by the academic program in which the student is enrolled). iii. Must work fewer than 20 hours per week iv. Must not be academically disqualified or on academic probation (refer to the college catalog) v. Non-GCCCD students must pass a Live Scan background check and TB test. Live Scan background checks and TB tests may be required by program needs (e.g. Child Development Center) for all student workers. vi. May not work more than a cumulative maximum of 6 academic years within the District. Work for any portion of an academic year constitutes one year. Summer school will count towards only one academic year and the cumulative maximum of 6 academic years applies. vii. Students who fall below the full-time threshold (but maintain 6 units) or are academically disqualified or on academic probation in the fall and spring semesters may complete work in the current semester only. If this occurs, student will not be employed the following semester and not be eligible for future employment until they have reached full-time status and good academic standing. These cases must be reviewed and approved by Human Resources. Professional Expert a. Work on a finite project that falls outside the skills and knowledge of existing positions within the classified service b. Must have specialized knowledge or expertise c. Recommendation of the appropriate Chancellor’s Cabinet level administrator is required. Non Academic and Non Classified Employees (NANCE) a. Unique positions that may be reoccurring from semester to semester, may be sporadic, and are dependent on student/program needs or specific contractual obligations that may fluctuate b. Must be directly correlated to classroom lecture and/or lab instruction only c. Positions are: Tutors, Teaching Assistants, Models, Interpreters, and Life Guards d. Employees in these positions may or may not be students i. Above Work-Study and Work-Experience student requirements will apply. All Other Student Workers requirements do not apply. e. Non-GCCCD students must pass a Live Scan background check and TB test. Live Scan background checks and TB tests may be required by specific programs (e.g. Child Development Center). f. Not intended to supplant classified work rev. 5/4/17 GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRICT HUMAN RESOURCES SUPPLEMENTAL QUESTIONNAIRE FOR PART-TIME (NON-FACULTY) HOURLY EMPLOYEES As a condition of employment, the information requested below must be provided (Reference Ed. Code Section 88022) for all potential (non-faculty) hourly employees with the District. The existence of a criminal record does not constitute an automatic bar to employment, with the exception of certain sex or drug offenses, specifically described by the California Education Code. In the cases of drug convictions, further consideration is given to personal rehabilitation efforts as well as a certificate of rehabilitation and pardon. Name: Address: Last First Mailing Address Potential hire for: City Department Social Security number State Zip Supervisor 1. Have you ever been convicted of a felony or any crime related to drugs, alcohol abuse, or moral turpitude? Note, expunged convictions must be reported. Yes No If yes, explain in detail including the conviction date and Penal Code, Vehicle Code, Health and Safety Code or other code provision of conviction: Code violation section number: Date of conviction: Convicted of: Place /city of occurrence: Disposition /Outcome: Code Violation Section Number: Date of Conviction: Convicted of: Place /City of Occurrence: Disposition /Outcome: Code Violation Section Number: Date of Conviction: Convicted of: Place /City of Occurrence: Disposition /Outcome: 2. If your answer to question 1 is “Yes”, have you received a certificate of rehabilitation or pardon, or has the accusation or information against you been dismissed pursuant to Penal Code Section 1203.4? Yes No If your answer to question 2 is “Yes”, you must provide evidence that substantiates that you have been rehabilitated. (Proof of rehabilitation can include but is not limited to: court documents, receipt of payment of fine, completion of required programs, etc.) Applicant’s Signature Date Grossmont-Cuyamaca Community College District EMPLOYEE INFORMATION FORM HUMAN RESOURCES PLEASE REFER TO THE CODING INFORMATION ON REVERSE WHEN NECESSARY TO COMPLETE THIS FORM. PLEASE TYPE OR PRINT CLEARLY IN BLACK INK. 1. DATE COMPLETED: 3. 2. SOCIAL SECURITY NUMBER NAME (As it appears on your Social Security Card) Last First 4. LOCATION: 5. BIRTH DATE: (G = Grossmont, C = Cuyamaca, D = District) 6. SALUTATION Mr. 7. MARITAL STATUS Mrs. Middle M/D/Y Ms. Dr. 8. GENDER (M = Male, F = Female) (D = Divorced, M = Married, S = Single, U = Unknown, W = Widowed, P =Separated) 9. HOME ADDRESS Number and Street City State Zip 10. PHONE NUMBER Cell Phone Secondary Phone email address: 11. PERMISSION TO RELEASE PHONE NUMBER (B = Both Faculty & Student, F = Faculty, S = Student, N= None ) 12. ETHNIC DATA: A) ARE YOU HISPANIC OR LATINO? (CHECK ONE) YES B) WHAT IS YOUR RACE/ETHNICITY? (LIST ONE OR MORE) ETHNIC GROUP (See reverse for Coding Information) 13. DISABLED (Y = Yes, N = No) If yes: PRIMARY DISABILITY NO SECONDARY DISABILITY (See reverse for Coding Information.) 14. CITIZEN (Y=Yes, N=No) 15. VETERAN (Y=Yes, N=No) ACTIVE (Y=Yes, N=No) RESERVE (Y=Yes, N=No) 16. PRIMARY EMERGENCY INFORMATION: Name: Last Relationship Phone: (day) First Middle I. (evening) SECONDARY EMERGENCY INFORMATION: Name: Last Relationship Phone: (day) First (evening) Middle I. EMPLOYEE INFORMATION FORM (Continued) NAME 17. EDUCATIONAL INFORMATION (Highest Level of Completion) (If additional space required, indicate in "Comments" section.) LHS (Less than High School) HS (High School) (Technical Trade) AA AS a. Degree Type: BA BS MA MS Ph.D. Other (please specify) Degree Awarded (Date: M/D/Y): Institution: Major: Minor: Description: IF HIRED AS AN ACADEMIC EMPLOYEE AND IF EMPLOYED ELSEWHERE, PLEASE COMPLETE: 18. PLACE OF EMPLOYMENT ADDRESS Street City State Zip PHONE NUMBER COMMENTS SECTION (to be used as needed): Employee Signature Date RACE/ETHNICITY INFORMATION CODES: (Indicate code in appropriate section--of front page.) CODING INFORMATION DISABILITY STATUS CODES: (More than one may be entered--indicate code in appropriate section--primary/secondary--of front page.) AC AI AJ AK Chinese Asian Indian Japanese Korean AL AM AV AX B F HM HR HS XH N PG PH PS PX W Laotian Cambodian Vietnamese Other Asian Black Non-Hispanic Filipino Mexican, Mexican-American, Chicano Central American South American Other Hispanic American Indian/Alaskan Native Guamanian Hawaiian Samoan Other Pacific Islander White Non-Hispanic M V O H S E Physical Disability (Mobility) Physical Disability (Visual) Physical Disability (Other Health) Communications Disability (Hearing) Communications Disability (Speech) Mental Disability (Emotional) GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRICT COMPUTER SYSTEM SECURITY AND USE STATEMENT I understand that the Grossmont-Cuyamaca Community College District (GCCCD) network represents an essential asset of the district and that misuse of networking resources may result in the loss of privileges. Users may be held accountable for their conduct under any applicable District/campus policy, procedure, or collective bargaining agreement. Under California state law anyone who maliciously accesses, alters, deletes, damages, or destroys any computer system, network, computer program or data is guilty of a felony. Complaints alleging misuse of network resources will be directed to those responsible for taking appropriate disciplinary action. I understand that the GCCCD computing systems are provided for the use of Grossmont/Cuyamaca Community College District students, faculty, and staff in support of the educational programs of the colleges, and are to be used for such activities only. Commercial uses are specifically prohibited. I agree to use the network in a legal and ethical manner which respects the rights, privacy, and needs of others, which honors copyright and license agreements, and which does not interfere with the operation, integrity, or security of the network. I understand that all communications are to reflect the mutual respect and civility expected in an academic community. I understand that I am responsible for all activity under my user name, and understand that abuse of the network privilege will result in the immediate suspension of network access. I understand that I may not transfer or confer these privileges to another individual, unless I provide explicit written permission to another person access to my e-mail accounts. The authorized user is responsible for the proper use of the system, including any password protection. I am aware that network traffic may be subject to search under court order. I understand that network traffic, and E-mail and voice mail in particular, may be considered a public record of the GrossmontCuyamaca Community College District. Such records are subject to examination by District officials in the necessary conduct of District business and release by request under provisions of California Government Code Section 6250 et.seq. System administrators may monitor network traffic or access user files as required to protect the integrity of the network. I am aware that all users have the right to be free from any conduct connected with the use of GCCCD computing systems which discriminates against any person on the basis of race, color, national origin, sex, sexual orientation, or disability or creates a hostile educational environment. Nothing in this statement supersedes the right of a network service provider to impose more restrictive terms. I have read the above GCCCD Computer System Security and Use Statement and agree to comply with all policies and procedures set forth by the Grossmont District. Identification Number Print Name Identification Number Signature Date Date For a complete statement clarifying District Computing operating guidelines and procedures, see District Administrative Procedure 3720, Computer and Network Use. 12/2008 Grossmont-Cuyamaca Community College District Oath of Allegiance and Citizenship Affidavit for persons employed by a school district of the State of California (Oath of Allegiance is required by Sections 3100-3109 of the Government Code) State of California County of San Diego I, do solemnly swear (or affirm) that I Print name will support and defend the Constitution of the United States and the Constitution of the State of California against all enemies, foreign and domestic; that I will bear true faith and allegiance to the Constitution of the United States and the Constitution of the State of California; that I will take this obligation freely, without any mental reservation or purpose of evasion, and that I will well and faithfully discharge the duties upon which I am about to enter. Are you a U.S. Citizen: Yes No If you are not a U.S. Citizen, can you provide documentation of your temporary or permanent legal right to work in the United States? Yes No Employee signature: Social Security number: Date: - - Social Security Administration Statement Concerning Your Employment in a Job Not Covered by Social Security Employee Name Employer Name Employee ID# GCCCD Employer ID# 95-6006652 Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be affected. Windfall Elimination Provision Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as a result of this provision is $395.50. This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall Elimination Provision.” Government Pension Offset Provision Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension. For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 $400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government Pension Offset.” For More Information Social Security publications and additional information, including information about exceptions to each provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office. I certify that I have received Form SSA-1945 that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social Security Benefits. Signature of Employee Form SSA-1945 (01-2013) Destroy Prior Editions Date NOTICE OF EXCLUSION FROM CalPERS MEMBERSHIP 1. SOCIAL SECURITY NUMBER 2. CURRENT NAME 3. NAME OF PUBLIC AGENCY Your employer has contracted with the California Public Employees’ Retirement System (CalPERS) to provide an employee benefit package which includes service retirement, death, and disability benefits. (LAST) (FIRST) (MIDDLE) DEPARTMENT OR SCHOOL DISTRICT 5. JOB OR POSITION TITLE IF TEMPORARY, ENTER NEAREST NUMBER OF WHOLE MONTHS THE APPOINTMENT IS EXPECTED TO LAST. 8. APPOINTMENT DATE MM DD YYYY 4. GCCCD 6. TERM OF APPOINTMENT PERMANENT 9. 7. TEMPORARY MONTHS TIME BASE FULL-TIME INDETERMINATE PART-TIME IF PART TIME, ENTER THE FRACTION OF FULL TIME: In your present position with this agency, you are excluded from CalPERS membership because: 1. Your full-time seasonal or limited term appointment is limited to 6 months or less. 2. Your part-time appointment is limited to less than an average of 20 hours per week for less than one year. 3. Your appointment is an on-call, intermittent, emergency, substitute, or other irregular basis which excludes you from membership until you have worked 1,000 hours (or 125 days if paid on per diem basis) this fiscal year. 4. Your position is excluded by law or by contract agreement which excludes: Enter contract exclusion (for Public Agencies only). 5. You are an independent contractor. 6. You are employed to render professional legal service to a city. Exceptions: Persons holding the office of city attorney, deputy city attorney, or assistant city attorney. 7. You are employed as a student aide by a school district in a position established for students only and you are attending school in the same district (for County Schools only). NOTE: If you are a member of CalPERS by previous employment (either you have funds on deposit or service credit), exclusions 1, 2, and 3 do not apply to you and you should be a member in your present position. Be sure to notify your employer to complete a (PERS-1) Member Action Request Form or appoint via ACES to report your employment to CalPERS. If you believe that your employment does qualify you for CalPERS membership, ask your employer for an explanation. If you still have doubts, you may appeal directly to CalPERS by sending a letter to the Actuarial & Employer Services Branch, Membership Analysis & Design Unit, P.O. Box 942709, Sacramento, CA 94229-2709, stating the reasons why you feel you should be a member. SIGNATURE OF CERTIFYING OFFICER TITLE SIGNATURE OF EMPLOYEE DATE DATE NOTE: Benefits provided by CalPERS are described in the “CalPERS Benefits” information booklet available from your employer. PERS-AESD-139 (3/08) California Public Employees’ Retirement System www.calpers.ca.gov California Public Employees’ Retirement System P.O. Box 942709 Sacramento, CA 94229-2709 888 CalPERS (or 888-225-7377) TTY: (877) 249-7442 | Fax: (916) 795-4166 www.calpers.ca.gov RECIPROCAL SELF-CERTIFICATION FORM Complete the following information and return this form to your Personnel Office within 10 business days: Employee Name (Last) (First) (Middle) Social Security Number or CalPERS ID Number: Check the applicable statement: _____ I have not been a member of CalPERS or of a qualifying Public Retirement System in California. _____ I was a member of CalPERS or a qualifying Public Retirement System in California and terminated my membership by withdrawing my funds. _____ I am retired from CalPERS. _____ I am retired from another Public Retirement System in California. _____ I am an active member of CalPERS. I have funds on deposit with CalPERS. _____ I am an active member of another Public Retirement System in California. (Complete the box below). Name of Most Recent Reciprocal System: Membership Date: Separation Date: Name of Prior Reciprocal System: Membership Date: Separation Date: Name of Prior Reciprocal System: Membership Date: Separation Date: I understand that by accepting employment in a specific retirement system, I am subject to the applicable laws and regulations of that system. I also understand that completing this form does not constitute a request to establish reciprocity. I must complete and return the form Confirmation of Intent to Establish Reciprocity When Changing Retirement Systems to CalPERS. I hereby certify that the foregoing information is true and correct and any information found to be incorrect may require corrections to my account in the California Public Employees’ Retirement System including, but not limited to, my date of membership. CalPERS may make any necessary corrections to my account to ensure I am properly enrolled and eligible to receive the correct retirement benefits. _________________________________________ Employee Signature _________________ Date TO BE COMPLETED BY EMPLOYER ONLY: Name of CalPERS Agency: Designee of Employer: (Print Name) CalPERS Business Partner ID: (Title) Designee’s Signature: Employees’ CalPERS Original Hire Date: Employees’ CalPERS Membership Eligibility Date: (Date) The employer must retain this form in the employee’s file for auditing purposes. PERS-CASD-801 (6/16) Page 3 of 4 California Public Employees’ Retirement System P.O. Box 942709 Sacramento, CA 94229-2709 888 CalPERS (or 888-225-7377) TTY: (877) 249-7442 | Fax: (916) 795-4166 www.calpers.ca.gov Employer Account Management Division Dear Member, You are being provided with the background, explanation, and instructions for the Reciprocal Self-Certification Form (PERS-CASD 801). With the implementation of The Public Employees’ Pension Reform Act of 2013 (PEPRA) on January 1, 2013, CalPERS requires that employers determine the applicable retirement benefit formula for new employees. The Reciprocal Self-Certification form allows you to provide essential information to your employer and will be used by your employer to enroll you into CalPERS membership. This information will assist in identifying your retirement benefit level 1. Reciprocity among public retirement systems is to allow members to separate from one public employer and enter into employment with another public employer within a specific time limit without losing valuable retirement and related benefit rights. Within 10 business days of employment you must complete, sign, date, and submit to your employer the Reciprocal Self-Certification form. When completing the form, reference the attached list of qualifying Public Retirement Systems in California. If applicable, list your previous membership date(s) in the qualifying Public Retirement System and your permanent separation date(s); OR indicate that you are not a current or past member of a qualifying Public Retirement System. The completion of the Reciprocal Self-Certification Form does not establish reciprocity and is not a request to establish reciprocity. In order to request that reciprocity be established, visit the CalPERS website, www.calpers.ca.gov and download the publication When You Change Retirement Systems. It is the responsibility of the employee to complete and send the form, Confirmation of Intent to Establish Reciprocity When Changing Retirement Systems to CalPERS. Sincerely, Membership Management Section Enclosures: List of Qualifying Public Retirement Systems in California, Reciprocal Self-Certification form 1 A new member is defined in the Public Employees’ Retirement Law (PERL) under Government Code section 7522, the Public Employees’ Pension Reform Act of 2013 (PEPRA), as any of the following: •A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has no prior membership in any California Public Retirement System. •A new hire who is brought into CalPERS membership for the first time on or after January 1, 2013, who has a break in service of greater than six months with another California Public Retirement System that is subject to Reciprocity. •A member who first established CalPERS membership prior to January 1, 2013, who is rehired by a different CalPERS employer after a break in service of greater than six months. PERS-CASD-801 (6/16) Page 1 of 4 List of Qualifying Public Retirement Systems in California Name of County/Agency/System: Alameda County^ City and County of San Francisco* City of Concord* City of Costa Mesa* City of Fresno City of Los Angeles City of Oakland City of Pasadena City of Sacramento* City of San Clemente* City of San Diego City of San Jose Contra Costa County^ Contra Costa Water District County of San Luis Obispo East Bay Municipal Utility District East Bay Regional Park District Fresno County^ Imperial County^ Judges’ Retirement System Kern County^ Legislators’ Retirement System Los Angeles County Metropolitan Transportation Authority Qualification(s): Safety Employees only Miscellaneous and Safety Retirement systems Non-Safety only Non-Safety only Fire and Police Only Non-Safety only Safety Employees only Non-Contract Employees’ Retirement Income Plan, formerly Southern California Rapid Transit District Los Angeles County^ Marin County^ Mendocino County^ Merced County^ Orange County^ Sacramento County^ San Bernardino County^ San Diego County^ San Joaquin County^ San Mateo County^ Santa Barbara County^ Sonoma County^ Stanislaus County^ State Teachers’ Retirement System Tulare County^ University of California Retirement System Ventura County^ *=Also CalPERS-covered agency PERS-CASD-801 (6/16) ^=1937 Act Counties Page 2 of 4 Privacy Notice The privacy of personal information is of the utmost importance to CalPERS. The following information is provided to you in compliance with the Information Practices Act of 1977 and the Federal Privacy Act of 1974. Information Purpose The information requested is collected pursuant to the Government Code (sections 20000 et seq.) and will be used for administration of Board duties under the Retirement Law, the Social Security Act, and the Public Employees’ Medical and Hospital Care Act, as the case may be. Submission of the requested information is mandatory. Failure to comply may result in CalPERS being unable to perform its functions regarding your status. Please do not include information that is not requested. Social Security Numbers Social Security numbers are collected on a mandatory and voluntary basis. If this is CalPERS’ first request for disclosure of your Social Security number, then disclosure is mandatory. If your Social Security number has already been provided, disclosure is voluntary. Due to the use of Social Security numbers by other agencies for identification purposes, we may be unable to verify eligibility for benefits without the number. Social Security numbers are used for the following purposes: 1. Enrollee identification 2. Payroll deduction/state contributions 3. Billing of contracting agencies for employee/ employer contributions 4. Reports to CalPERS and other state agencies 5. Coordination of benefits among carriers 6. Resolving member appeals, complaints, or grievances with health plan carriers Information Disclosure Portions of this information may be transferred to other state agencies (such as your employer), physicians, and insurance carriers, but only in strict accordance with current statutes regarding confidentiality. Your Rights You have the right to review your membership files maintained by the System. For questions about this notice, our Privacy Policy, or your rights, please write to the CalPERS Privacy Officer at 400 Q Street, Sacramento, CA 95811 or call us at 888 CalPERS (or 888-225-7377). May 2016 Grossmont-Cuyamaca Community College District HUMAN RESOURCES VERIFICATION OF MEMBERSHIP IN A CALIFORNIA PUBLIC RETIREMENT SYSTEM PLEASE TYPE OR PRINT CLEARLY IN BLACK INK. NAME: (Please Print) Last Social Security No. First / M.I. / Birthdate: / / Are you now or have you ever been a member of the California State Teachers Retirement System (STRS)? (Check One): Yes No (If "no" is checked, sign and date below.) If "yes" marked above, please complete the following: In what California county did you last serve? Agency last served? In what year? Under what name? In what position? hourly substitute, child care.) (If as a teacher indicate contract, If monthly employee, what percent were you employed? (30%) (50%) (75%) etc. Are you currently a member of the STRS? Yes No If you checked NO: List date you withdrew your funds: OR **List date you retired: (Retired means receiving a monthly benefit payment) **The Education Code prohibits employment in a classified position while a retiree of STRS. You may be employed in any certificated position, kindergarten through community college; however, there is a restriction on the amount you can earn without affecting your STRS retirement allowance. In addition, a Form I-30 must be submitted to the County Department of Education prior to your return to employment in a certificated position. The facts you have furnished as to your public agency retirement membership status are to enable the GrossmontCuyamaca Community College District and the San Diego County Office of Education to determine and verify your retirement status with the retirement system. If you are a current member of STRS and have not indicated so on this form, you are immediately liable for retirement contributions not deducted from your earnings. Your status in STRS will determine whether ARS retirement contributions will be deducted. Signature Rev. 1/2013 Date MEMORANDUM TO: All District Employees FROM: Kim Frost Payroll Services Supervisor SUBJECT: Direct Deposit Direct Deposit is available to every employee - Full Time, Part Time, Adjunct, and hourly so sign up today! Direct Deposit is Simple ● Signing up is easy, you will fill out the form once and it’s done! ● Making changes is simple! You are always in control! ● Multiple bank accounts- no problem! Direct Deposit is Convenient ● Once you have signed up, no need to go to the bank to make deposits! ● Save yourself the time and hassle of standing in long lines at the bank! ● Your money is automatically deposited on payday – on time – every time! ● No hassles during emergencies- your paycheck will always be there! ● It does not matter where you are on payday! Your check is deposited for you! ● You have 24 Hour access to view your paystubs on line! Direct Deposit is Safe ● Direct Deposit never gets lost! ● It is confidential and transfers electronically! ● Paper checks potentially can be lost or damaged and take some time to replace! Complete the attached form and submit to payroll. Forms are also available at http://www.gcccd.edu/formsdepot If you have any questions, please contact Payroll Services at (619)644-7902. GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRICT DIRECT DEPOSIT AUTHORIZATION PRINT or TYPE NAME SOCIAL SOCIAL SECURITY SECURTIY NUMBER NO. WORK SITE PHONE EXT./VOICE MAIL # I hereby authorize the above named District and/or their agents, to initiate electronic deposits via the Automated Clearing House (ACH) and, as necessary, debit corrections to previous deposits, to the following account(s). I understand: I must submit a new authorization form if I close/change my account (name, branch, etc.); failure to do so may result in a deposit delay. Direct deposit status may be temporarily suspended if wages are garnished. It is my responsibility to keep apprised of any deposit(s) made to my account(s) including dates and amounts of any such deposit(s). This document must be received in Payroll no later than the 10th of the month in which it will be effective. I agree to hold harmless and indemnify the District and their officers, employees and agents from any claim or demand of whatever nature, including those based upon negligence of the District and their officers, employees, and agents for failure or delay in making deposits and/or corrections to deposits as herein authorized. This authorization replaces any previously made by me and is to remain in effect until changed or canceled by submission of a new Direct Deposit Authorization form. Signature Date DEPOSIT INSTRUCTIONS: New ACH Set Up ACH Amount Change ACH Cancellation Name of Financial Institution Address of Financial Institution Financial Institution Transit Routing No (Check with financial institution to confirm Transit Routing Number and Account Number for accuracy.) CHECKING: NET CHECK ACCOUNT NUMBER: OR $ (ATTACH VOIDED BLANK CHECK) SAVINGS: NET CHECK ACCOUNT NUMBER: OR $ SIGNED ORIGINAL – RETURN TO PAYROLL OFFICE Grossmont-Cuyamaca Community College District EMPLOYEE’S DESIGNATION OF BENEFICIARY Designation of person to receive and negotiate warrants after death under Government Code Section 53245* Employee name Social Security Number This is to inform you that in the event of my death I hereby designate: Name as the person entitled to receive and negotiate all warrants or checks that will be payable to me from the Grossmont-Cuyamaca Community College District. This designee is: Spouse Parent Child (other) He/she may be identified as follows: Date of birth Place of birth I understand that it is my responsibility to keep this designation current, and further, I understand that this designation is in addition to , and separate from, the beneficiary designation filed with the State Teachers’ Retirement System, the Public Employees’ Retirement System, the County Employees’ Retirement System, or in any other will, codicils or like documents. Signature Date filed * Government Code, Section 53245 – “Any person now or hereafter employed by a county, city, municipal corporation, district or other public agency may file with his/her appointing power a designation of a person who, notwithstanding any other provision of law, shall, on the death of the employee, be entitled to receive all warrants or checks that would have been payable to the decedent had he/she survived. The employee may change the designation from time to time. A person so designated shall claim such warrants or checks from the appointing power. On sufficient proof of identity, the appointing power shall deliver the warrants or checks to the claimant. A person who received a warrant or check pursuant to this section is entitled to negotiate it as if he/she were the payee.” Original – Human Resources Copy - Employee Grossmont-Cuyamaca Community College District RECEIPT OF WORKERS’ COMPENSATION INFORMATION By signing below, I acknowledge that I have received the WellComp MPN – Informational Pamphlet and the Facts about Workers’ Compensation and Pre-designation of Personal Physician Form, documents that contain important information regarding workers’ compensation. Date 1/2013 Rev. 10/2013 Print Name Signature ID# The physician is not required to sign this form, however, if the physician or designated employee of the physician or medical group does not sign, other documentation of the physician’s agreement to be pre-designated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3). (Optional DWC Form 9783 July 1, 2014) (Physician or Designated Employee of the Physician) Signature:________________________________Date____________ Physician: I agree to this Pre-designation: Employee #_________________________ Date_________________ Employee Signature__________________________________________ Note to Employee: Unless you agree in writing, neither your employer or York may contact your personal physician to confirm a pre-designation. If your physician does not sign this form, other documentation that they agreed to be pre-designated prior to the injury will be required. If you agree, your employer or York may contact your personal physician to confirm this predesignation, sign and date below: Employee Signature:_______________________Date__________ ________________________________________________________ Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational injuries or illnesses: _____________________________ Employee’s Address:_________________________________________ Employee Name (please print): _________________________________ _______________________________________________________ (telephone number) _______________________________________________________ (street address, city, state, zip) If I have a work-related injury or illness, I choose to be treated by: _______________________________________________________ (Name of doctor) (M.D., D.O., or medical group) Employer ________________________________________________ Notice Of Pre-designation Of Personal Physician Employee: Complete this section You may use this form, a form provided by your employer or provide all the information in writing to notify your employer if you wish to have your personal medical doctor or a doctor osteopathic medicine treat you for a workrelated injury/illness and the above requirements are met. In the event you sustain an injury or illness related to your employment, you may be treated for such injury/illness by your personal medical doctor (M.D) or doctor of osteopathic medicine (D.O.) or medical group if: You have health care insurance for injuries/illness that are not work related, the doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or boardeligible internist, pediatrician, obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, and retains your medical records; your “personal physician” may be a medical group if it is a single corporation or partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for non-occupational illnesses and injuries; prior to the injury your doctor agrees to treat you for work injuries or illnesses; prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-related injury/illness, and (2) your personal doctor’s name and business address. Pre-designation Of Personal Physician Call 9-1-1 for help immediately if emergency medical care is needed. Immediately report injuries to your supervisor or employer representative at __Company Nurse 888/770-0929 OR Benefits © 7/1/14 YORK. All rights reserved Employer MUST complete this information __________________________________________________________ _______________________________________________________________ Information & Assistance Office:___7575 Metropolitan Drive Suite 202, _ _ __San Diego, CA 92108-4424_____619/767-2082______________________ 619/644-7643________________________ Quickly seek first aid. WHEN A WORK INJURY OCCURS… Date:________________________________________________ Title 8, California Code of Regulations, section 9783.1 (Optional DWC Form 9783.1 Effective date July 1, 2014) Employee’s Signature:___________________________________ ___________________________________________________ Employee’s Address:____________________________________ Employee Name (Please Print):_____________________________ ____________________________________________________ (telephone number) __________________________________________________ (street address, city, state, zip code) __________________________________________ ________ Name of chiropractor or acupuncturist (D.C., L.AC.) If your employer or your employer’s insurer does not have a Medical Provider Network (MPN), you may be able to change your treating physician to your personal chiropractor (D.C.) or acupuncturist (L.AC.) following a work-related injury/illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal D.C. or L.AC. in writing prior to the injury/illness. York generally has the right to select your treating physician within the first 30 days after your employer knows of your injury/illness. After your employer or York has initiated your treatment with another physician during this period, you may then, upon request, have your treatment transferred to your personal D.C. or L.AC. You may use this form to notify your employer of your personal D.C. or L.AC., or your employer may have their own form. The D.C. or L.AC. must be your regular D.C. or L.AC. who has directed your treatment and retains your chiropractic records and history. If your employer has an MPN, you may only switch to a D.C. or L.AC. within the MPN. A chiropractor cannot be your treating physician after 24 visits. If you still require medical treatment thereafter, you will have to select a physician who is not a chiropractor. This prohibition shall not apply to visits for postsurgical physical medicine visits prescribed by the surgeon, or physician designated by the surgeon, under the postsurgical component of the Division of Workers’ Compensation’s Medical Treatment Utilization Schedule. Or Personal Acupuncturist Notice Of Personal Chiropractic Approved by Division of Workers’ Compensation York Risk Services Group, Inc. P.O. Box 619079 Roseville, CA 95661 Phone (866) 221-2402 Fax (866) 548-2637 The Facts About Workers’ Compensation Medical Care: Medical treatment that is reasonably required to cure or relieve the injured worker from the effects of the injury/illness. There is no deductible or co-payment. These medical benefits may include lab tests, physical therapy, hospital services, medication and treatment by a doctor. What are the benefits? You may be entitled to various kinds of benefits under California workers’ compensation law including: Within one working day, upon knowledge or notice from any source of a work injury/illness greater than first-aid, provide the employee with a Claim Form (DWC-1) and authorize medical treatment and report the claim to York Risk Services Group. Duty of the Employer: Provide this form to every employee at the time of hire or by the end of their first pay period. Your claim benefits do not start until your employer knows about your injury, so report and file the DWC-1 as quickly as possible. California law requires your employer to authorize medical treatment within one working day of receipt of your Claim Form. Employers are liable for up to $10,000 in treatment pending a decision by York for a claim to be accepted or rejected. Waiting to report may delay workers’ compensation benefits. You may not receive benefits if you fail to file a claim within one year of the date of injury, the date you know the injury was work related, or the date benefits were last provided. Duty Of The Employee. Immediately notify your employer or York so you can get the medical help that you need without delay. If your injury is greater than a first-aid injury, your supervisor will give you a Claim Form (Form DWC-1) for you to describe where, when and how it happened. To submit a claim, fill out the “Employee” section of the DWC-1. Keep one copy of this form and give the remaining pages to your supervisor. Your employer will fill out the “Employer” section and return a signed and dated copy of the form to you. Your employer will keep a copy of this form and forward another to York. York is in charge of handling your claim and informing you about your eligibility for benefits. What Does Workers’ Compensation Cover? If you have an injury/illness due to your job, it is covered. The cause can be a single event, like a fall or it can be due to repeated exposures, such as hearing loss due to constant loud noise. Injuries ranging from first-aid to serious accidents are covered. Even injuries related to a workplace crime, such as psychological or physical injuries, are covered under workers’ compensation. Some injuries that result from voluntary activity, such as off duty social or athletic activities may not be covered. Check with your employer or York if you have questions. Coverage begins the moment you start your job. There is no probationary period or wage rate. Am I Covered? Nearly every person employed in California is protected by workers’ compensation, however there are a few exceptions. People that are selfemployed or volunteer workers may not be covered. Similar laws cover federal and maritime workers. York Risk Services Group (York) is your employer’s claims administrator. Your employer or York can answer any questions you might have about coverage. What is workers’ compensation? Its purpose is to insure that an employee who is found to sustain an industrial injury or illness will be provided with benefits to medically cure or relieve them from the effects of the injury/illness, provide temporary compensation when they are medically unable to perform any occupational function, compensation for any residual handicap and/or impairment of bodily function, benefits for dependents if an employee dies as a result of an injury/illness, protection from discrimination by his/her employer because of the injury/illness. Permanent Disability: If your doctor says your injury will always leave you with some permanent impairment of bodily function(s), you may receive permanent disability (PD) payments. The amount depends on the doctor’s report, how much of the PD was directly caused by your work, and factors such as your age, occupation, type of injury, and date of injury. State law determines minimum and maximum amounts, and they vary by injury date. If you are entitled to PD, York will send you a letter explaining how the benefit was calculated. If the injury Temporary Disability Benefits: If you are not medically able to work for more than three days due to your work-related injury, counting weekends, you have a right to temporary disability (TD) payments to assist substituting your lost wages. After two weeks from reporting the injury, you will receive a check. If your employer has a salary continuation plan, your benefit may be included in your regular paycheck. TD is payable every 14 days until the doctor states you can return to work (Payments won’t be made for the first three days, though, unless you’re hospitalized as an inpatient or unable to work more than 14 days). The amount of the payments will be two-thirds of your average wage, subject to minimums and maximums set by the state legislature. Although the TD payment will not be the full amount of your regular paycheck, there are no deductions and the payments are tax-free. For injuries occurring on or after January 1, 2008, TD payments are limited to 104 compensable weeks within five years of date of injury. For a few long-term injuries such as chronic lung disease or severe burns, TD payments can last up to 240 weeks within five years from the date of injury. If you reach the maximum TD payment period before you can return to work or before your condition becomes permanent and stationary. See the “Other Benefits” section of this pamphlet for additional in information. A timely filing with Employment Development Department may result in additional State Disability benefits when TD benefits are delayed, denied, or terminated. If you give the name of your personal chiropractor or acupuncturist, different rules apply, and you may need to see an employer-selected physician first. You can be treated by your personal physician or medical group immediately if you have health care insurance for injuries or illness that are not work related, and your physician agrees in advance to treat you for any work injuries/illnesses and has previously directed your treatment and retains your medical records and agrees, prior to your injury/illness, to treat you for workplace injuries/illnesses and you gave your employer your physician’s name and address in writing before the injury. You may use the form inside of this pamphlet or your employer may have a form for you to use. The physician with overall responsibility for treating your injury/illness is your primary treating physician (PTP). The PTP decides what kind of medical care you need and if you have work restrictions. If necessary, the PTP will review your job description with you and your employer to define any limitation or restrictions that you may have. This doctor also is responsible for coordinating care between other medical providers and will write reports about any permanent impairment of bodily function(s) or the need for future medical care. Generally, your employer selects the PTP you will see for the first 30 days, but if you want to change doctors for any reason, ask your employer or York. They’re as interested as you are in your prompt recovery and return to work and will select a different doctor for you. If your employer has a Medical Provider Network (MPN) you will be directed to treat with a physician within the MPN and different rules apply regarding changing your physician. State law limits certain medical services as of January 1, 2004. You should never receive a medical bill. If additional treatment is necessary, York will coordinate medical care that meets applicable treatment guidelines for the injury. The doctor may be a specialist for your specific type of injury, and he or she will be familiar with workers’ compensation requirements and will report promptly to York so your benefits can be paid. Anyone who makes or causes to be made any knowingly false or fraudulent material statement for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony. Fines can be up to $150,000 and imprisonment up to five years. WORKERS’ COMPENSATION FRAUD IS A FELONY If You Still Have Questions…ask your supervisor or employer representative. Or contact York at the number indicated on workers’ compensation posters at work and on this brochure. You can also contact the State Division of Workers’ Compensation (DWC) and speak with an Information and Assistance Officer. These officers are available to review problems, answer questions and provide additional written information about workers’ compensation at no charge. The local office is listed below and posted at your workplace. You can also call 800-736-7401 or visit the DWC website at: http://www.dir.ca.gov/dwc. You may be eligible to access the return-to-work fund, for the purposes of making supplemental payments to injured worker’s whose PD benefits are disproportionately low in comparison to their earnings loss. If you have questions or think you qualify, contact the Information & Assistance office listed in this pamphlet or visit the DIR website at: www.dir.ca.gov. Other Benefits: Sometimes people confuse workers’ compensation with State Disability Insurance (SDI). Workers’ compensation covers on-the-job injuries/ illnesses and is paid for by your employer or their insurance. On the other hand, SDI covers off-the-job injuries or sicknesses, and is paid for by deductions from your paycheck. If you are not getting workers’ compensation benefits, you may be able to get State Disability benefits. Contact the local office of the State Employment Development Department listed in the government pages of your phone book for more information. Discrimination: It a violation of Labor Code Section 132(a) and illegal for your employer to punish or fire you for having a workplace injury/illness, for filing a claim or for testifying in another person’s workers’ compensation case. If your employer is found guilty of discrimination, you would be entitled to increased benefits, reinstatement and reimbursement for lost wages and benefits. Death Benefits: If the injury/illness causes death, payments may be made to your dependents. State law sets these benefits and the total benefit depends on the number of dependents. The payments are made at the same rate as TD payments. In addition, workers’ compensation provides a burial allowance. Supplemental Job Displacement Benefit (SJDB): If you have a permanent whole person impairment, the eligibility for SJDB begins when your employer does not offer regular work, permanent, modified, or alternative work within 60 days of the receipt of a doctor’s Medical Maximum Improvement (MMI) report. This is a nontransferable voucher for education-related retraining and/or skill development at state-approved schools, tools, licensing, certification fees and other resources as possible benefits. If you qualify for the supplemental job displacement benefit, York will provide a voucher up to a maximum of $6,000. causes PD, the first payment of PD benefits is made within 14 days after the last payment of TD, unless your employer has offered you a position that pays at least 85% of your date of injury wages or if you are returned to a position that pays you 100% of the wages and, compensation paid to you on the date of injury, the PD would be paid after an Award issues. If the second opinion, third opinion or IMR agrees with your treating doctor, you will need to continue to receive medical treatment with a network physician. If the IMR does not agree with your treating network physician, you will be allowed to receive that medical treatment from a provider either inside or outside of the WellComp Network. If you disagree with the diagnosis or treatment plan determined by the third opinion physician, you may file the completed Independent Medical Review Application form with the Administrative Director of the Division of Workers’ Compensation. You may contact your claims examiner or the WellComp Patient Services Department for information about the Independent Medical Review process and the form to request an Independent Medical Review. Review (IMR) n Obtaining an Independent Medical ü Notify your claims examiner who will provide you with a regional area listing of physicians and/or specialists within the WellComp Network who have the recognized expertise to evaluate or treat your injury or condition. ü Select a physician or specialist from the list. ü Within 60 days of receiving the list, schedule an appointment with your selected physician or specialist from the list provided by your claims examiner. Should you fail to schedule an appointment within 60 days, your right to seek another opinion will be waived. ü Inform your claims examiner of your selection and the appointment date so that we can ensure your medical records can be forwarded in advance of your appointment date. You may also request a copy of your medical records. ü You will be provided information and a request form regarding the Independent Medical Review (IMR) process at the time you select a third opinion physician. Information about the IMR process can be found in the MPN Employee Handbook. If you disagree with the diagnosis or treatment plan determined by your treating physician or your second opinion physician, and would like a second or third opinion, you must take the following steps: n Obtaining Second and Third Opinions If you disagree with your doctor or do not like your doctor for any reason, you may always choose another doctor in the MPN. Second Opinion, Third Opinion and Independent Medical Review Process: Emergency services including outpatient and out-of area emergency care Examples of ancillary care providers include: diagnostic lab or x-ray services, physical medicine, occupational therapy, medical and surgical equipment, counseling, nursing, medically appropriate home care, medication. Ancillary Care services Examples of inpatient hospital and outpatient surgery center providers include: acute hospital services, general nursing care, operating room and related facilities, intensive care unit and services, diagnostic lab or x-ray services, necessary therapies. Inpatient Hospital and Outpatient Surgery Center services Examples of primary treating or specialty providers include: general medical practitioners, chiropractors, dentists, orthopedists, surgeons, psychologists, internists, psychiatrists, cardiologists, neurologists. Primary treating and specialty services including consultations and referrals The following is a summary of Workers’ Compensation medical services that are available to employees covered by the WellComp Network. Covered Medical Services: WellComp has providers throughout California. If a situation arises which takes you out of the coverage area, such as temporary work, travel for work, or living temporarily or permanently outside the MPN geographic service area, please contact the WellComp Patient Services Department, your claims examiner, or your primary treating provider, and they will provide you with a selection of at least 3 approved out-of-network providers from whom you can obtain treatment or get second and third opinions from the referred selection of physicians. n Treatment Outside of the Geographic Area Rev 6/10 Este folleto esta disponible en el Español. Para una copia gratis, favor de llamar a WellComp. This pamphlet is available in Spanish. For a free copy, please contact WellComp. Patient Services Department P.O. Box 59914 Riverside, CA 92517 Toll Free (800) 544-8150 fax: (888) 620-6921 or e-mail: [email protected] WellComp To access more information, regarding the WellComp Network, go to www.WellComp. net/download/. You can download the Employee Handbook, Transfer of Care Policy or the Continuity of Care Policy. To receive a hard copy of this information please contact WellComp. MPN Liaison: Gale Chmidling, MPN Manager (800) 544-8150 WellComp Information To access a directory of medical providers in the WellComp Network, go to www.WellComp.net where you can search by medical specialty, zip code, physician or provider group. To receive a hard copy of the regional area listing or the complete WellComp directory, please contact WellComp (your employer’s designated medical provider network administrator): WellComp Provider Directory Medical Treatment for Workers’ Compensation MPN Liaison, Gale Chmidling, MPN Manager P.O. Box 59914 Riverside, CA 92517 Toll Free (800) 544-8150 fax: (888) 620-6921 or e-mail: [email protected] Employee Name: __________________ Employer Name: __________________ Date of Injury: __________________ ü Find out if you are covered ü Access medical care ü Learn about continuity of care ü Choose your own physician ü Transfer into the WellComp Network ü Contact WellComp This pamphlet contains important information on accessing the WellComp Medical Provider Network: For treatment authorization contact WellComp Provider Services. For WellComp Patient Services: Toll Free (800) 544-8150 fax: (888) 620-6921 For emergency care or necessary treatment while the employee is outside of the state of California, please notify WellComp to facilitate authorization, billing and payment, as well as transfer of care. This employee is covered by the WellComp Network for workers’ compensation medical care. Possession or use of this card does not guarantee eligibility for benefits. Treatment must be furnished or referred by a WellComp medical provider with the exception of emergency care or necessary treatment while the employee is out of the state of California. All treatment requires pre-authorization except for emergency care. # This card is not required to receive medical services. In the event that you have an injury or illness, please complete the front of this card and carry it with you to present to your medical service providers for access to care. Your employer has elected to provide you with the choice of a broad scope of medical services for work-related injuries and illnesses by implementing a Medical Provider Network (MPN), called WellComp. WellComp delivers quality medical care through your choice of a provider who is part of an exclusive network of healthcare providers, each of whom possess a deep understanding of the California workers’ compensation system and the impact their decisions have on you. Your employer has received the approval from the State of California to cover your workers’ compensation medical care needs through the WellComp Network. You are automatically covered by the WellComp Network if your date of injury or illness is on or after your employer’s implementation date and if you have not properly pre-designated a personal physician prior to your injury or illness. Welcome to WellComp If you are having difficulty scheduling an appointment with your initial provider or subsequent provider, please contact your WellComp Patient Services Department. n Scheduling Appointments If you still require treatment after your initial evaluation with your employer’s designated provider, you may access the WellComp Directory and select an appropriate physician of your choice who can provide the necessary treatment for your condition or illness. For assistance determining physician options, please contact the WellComp Patient Services Department or discuss your options with your initial care provider. n Choosing a Treating Physician Your primary treating provider in the WellComp Network will make all of the necessary arrangements and referrals for specialists, inpatient hospital, outpatient surgery center services, and ancillary care services. n Hospital and Specialty Care In an emergency, defined as a medical condition starting with the sudden onset of severe symptoms that without immediate medical attention could place your health in serious jeopardy, go to the nearest healthcare provider regardless of whether they are a WellComp participant. If your injury is work-related, advise your emergency care provider to contact WellComp to arrange for a transfer of your care to a WellComp provider at the medically appropriate time. n Emergency Care If you still need treatment following your initial evaluation, you may be treated by a physician of your choice, or the initial physician may refer you to a medically and geographically appropriate specialist within the network who can provide the appropriate treatment for your injury or condition. Your employer is required to provide you with at least three physicians of each specialty expected to treat common injuries experienced by injured employees based on your occupation or industry. These physicians will be available within 30 minutes or 15 miles of your workplace or residence and specialists will be available within 60 minutes or 30 miles of your residence or workplace. For a directory of providers, please visit www.WellComp.net or call WellComp Patient Services. n Subsequent Care In case of an emergency, you should call 911 or go to the closest emergency room. In the event that you experience a work-related injury or illness, immediately notify your supervisor and obtain medical authorization from your employer to designate an initial care provider within the network. If you are unable to reach your supervisor or employer, please contact the patient services department at WellComp. For non-emergency services, the MPN must ensure that you are provided an appointment for initial treatment within 3 business days of your employer’s or MPN receipt of request for treatment within the MPN. n Initial Care If the contract with your doctor was terminated or not renewed by WellComp for reasons relating to medical disciplinary cause or reason, fraud or criminal activity, you will not be allowed to complete treatment with that doctor. For a complete copy of the Continuity of Care policy, please visit www.WellComp.net or call WellComp Patient Services. If any of the above conditions exist, WellComp may require your doctor to agree in writing to the same terms he or she agreed to when he or she was a provider in the WellComp Network. If the doctor does not, he or she may not be able to continue to treat you. • (Acute) A medical condition that includes a sudden onset of symptoms that require prompt care and has a duration of less than 90 days. • (Serious or Chronic) Your injury or illness is one that is serious and continues without full cure or worsens and requires ongoing treatment over 90 days. You may be allowed to be treated by your current treating doctor for up to one year, until a safe transfer of care can be made. • (Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less. • (Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN contract termination date. If you are being treated for a work-related injury in the WellComp Network and your doctor no longer has a contract with WellComp, your doctor may be allowed to continue to treat you if your injury or illness meets one of the following conditions: What if I am being treated by a WellComp doctor and the doctor leaves WellComp? Your employer has a written “Continuity of Care” Policy that may allow you to continue treatment with your doctor if your doctor is no longer actively participating in WellComp. n Continuity of Care If your primary treating provider makes a referral to a type of specialist not included in the network, you may select a specialist from outside the network. For non-emergency specialist services, the MPN must ensure that you are provided an appointment within 20 business days of your employer’s or MPN receipt of a referral to a specialist within the MPN. 1. Your primary treating provider in the WellComp Network can make all of the necessary arrangements for referrals to a specialist. This referral will be made within the network or outside of the network if needed. 2. You may select an appropriate specialist by accessing the WellComp Directory. 3. You may contact WellComp Patient Services who can help coordinate necessary arrangements. As long as you continue to require medical treatment for your injury or illness, there are alternatives for obtaining a referral to a specialist: n Obtaining a Specialist Referral If you find it necessary to change your treating physician and it is determined that you require ongoing medical care for your injury or illness, you may select a new physician from the WellComp Directory and schedule an appointment. Once your appointment is scheduled, immediately contact WellComp Patient Services who will then coordinate the transfer of your medical records to your new provider. n Changing Primary Treating Physician If your treating doctor believes that your condition does meet one of those listed above, you may continue to treat with him or her until the dispute is resolved. For a complete copy of the Transfer of Care policy, please visit www.WellComp.net or call WellComp Patient Services. If your treating doctor agrees that your condition does not meet one of those listed above, the transfer of care will go forward while you continue to disagree with the decision. If either WellComp or you do not agree with your treating doctor’s report, this dispute will be resolved according to Labor Code Section 4062. You must notify WellComp Patient Services Department, if you disagree with this report. If WellComp is going to transfer your care and you disagree, you may ask your treating doctor for a report that addresses whether you are in one of the categories listed above. Your treating physician shall provide a report to you within twenty calendar days of the request. If the treating physician fails to issue the report, then you will be required to select a new provider from within the MPN. n Care Transfer Disputes • (Acute) The treatment for your injury or illness will be completed in less than 90 days. • (Serious or Chronic) Your injury or illness is one that is serious and continues without full cure or worsens over 90 days. You may be allowed to be treated by your current treating doctor for up to one year from the date of receipt of the notification that you have a serious chronic condition. • (Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less. Treatment will be provided for the duration of the terminal illness. • (Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date. You will not be transferred to a doctor in WellComp if your injury or illness meets any of the following conditions: If your current treating physician is not a participating physician within WellComp, you are not covered under the MPN and your physician can make referrals to providers within or outside the MPN. If your current treating doctor is a member of WellComp, then you may continue to treat with this doctor and your treatment will be under WellComp. Your current doctor may be allowed to become a member of WellComp. Your employer has a “Transfer of Care” policy which describes what will happen if you are currently treating for a work-related injury with a physician who is not a member of the WellComp Network. What if you are already being treated for a work-related injury before the WellComp Network begins? n Transfer of Ongoing Care Access to Medical Care -14- ACKNOWLEDGEMENT OF RECEIPT SAFETY TIPS AND RIGHT TO KNOW Employee: I, the undersigned, hereby certify that I have received and read the booklet, Safety Tips and Right to Know. I further understand that willfully neglecting the safety measures could lead to discipline. Please check appropriate box: Full-Time Academic Full-Time Classified Part-Time Academic (includes part-time instructors, part-time counselors, librarians, or hourly academic substitutes) Part-Time Classified (i.e., work study, student worker, short term, classified substitutes and hire-a-youth) Department Grossmont Cuyamaca District Print Name Last First MI ID # Signed Dated RETURN WITH HIRE PACKET TO THE GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRICT HUMAN RESOURCES Human Resources Use Only Transposed to Insight; use LicnCert code “SK” 02-0153-014W (09/04/bg) By: __________ (initials) Date:_____________ 3121 Plan Overview (For Employee Use) Who Is Offering The San Diego County Schools FBC 3121 Plan? It is a partnership between San Diego County Board of Education Fringe Benefits Consortium, Life Insurance of the Southwest (LSW), and National Benefit Services, Inc. What Is The San Diego County Schools FBC 3121 Plan? The 3121 Plan is a savings program for employees who are not eligible to participate in the State Employees’ Retirement System. How the 3121 Plan Came About The Omnibus Budget Reconciliation Act of 1990 (OBRA) Amended the Internal Revenue Code and the Social Security Act to include employees of state and local governments. The Act authorized the Secretary of the Treasury to adopt regulations and provide guidance to the Internal Revenue Service and Social Security Administration. The Act amended Internal Revenue Code Section 3121, under which Social Security participation became mandatory for all employers. However, the Internal Revenue Code Section 3121 says that part-time, temporary, and seasonal (PTS) employees are exempt from the 3121 tax if they are provided a “comparable retirement system”. In response, the 3121 Plan was created to meet those requirements. This alternative provides a retirement plan for PTS employees who are not normally covered like full time employees. The adoption of the 3121 Plan provides an economic benefit for the employer and their PTS employees. How The 3121 Plan Benefits The Employee Social Security Costs Without the 3121 Plan, the employee must pay 6.2% after-tax into Social Security and the employer must also contribute 6.2% of pay. Employee Account With the 3121 Plan, the employee may be required to contribute up to 7.5% pre-tax (instead of 6.2% after tax) of gross compensation. The district may choose to contribute a portion of the required 7.5%. Employee Benefits Mandatory pre-tax contributions, which may reduce the amount of your current income which is subject to tax Possible District contributions to your account Tax-deferred savings, which means you pay no taxes on your investment earnings as long as they remain in the Plan Interest earnings are credited to employee 24/7 access to account info by accessing the website www.fbcretire.com/3121 Annual statement mailed to residence No front end sales charge No back end surrender charge Money available to withdraw on termination If you change jobs, you may be eligible to retain your funds in the plan until you request a withdrawal No 10% premature distribution tax Rollover/Transfer options 100% vested in account Question and Answer Overview (Employee Use) 1. What is the 3121 Plan? The 3121 Plan is a savings program for employees who are not eligible to participate in the State Employees’ Retirement System. 2. Why is this option different than paying Social Security? You are assured that your contributions and earnings are available to you when you terminate or retire and are no longer working for the school district. 3. Will my eligibility to receive Social Security benefits be affected by my participation in this Plan? Your Social Security benefit and your eligibility to receive that benefit may be affected by your participation in this plan. We suggest that you contact the Social Security Administration Department with any questions regarding your benefit. 4. Who is eligible to participate in this Plan? If your district has adopted this Plan, all part-time, temporary, or seasonal (PTS) employees are automatically enrolled and contributing to the plan. 5. Can I choose not to participate in the Plan? No. If your district adopts the plan, you must participate in this plan. 6. How much do I contribute? You may be required to contribute up to 7.5% pre-tax (instead of 6.2% after tax) of gross compensation. The district may choose to contribute a portion of the required 7.5%. 7. How will my money be invested? Your account will be invested in a fixed account with Life Insurance of the Southwest (LSW). The objective of this fund is to preserve principal while providing moderate growth. 8. Will I receive a statement of my account balance? Yes, you will receive a semiannual statement from Life Insurance of the Southwest. 9. How do I change my name, address, or beneficiary? a. The name reflected on the Payroll System is the “social security name”. In order to change your name in the Payroll System, the Retirement department requires a copy of the social security card (reflecting your new name). You are responsible for providing the Retirement department with the social security card reflecting your name change. b. To change your address, you must notify your district Payroll department. The district Payroll department will then be responsible for notifying San Diego County Office of Education FBC Deferred Compensation Plan of any address changes. c. If you are no longer employed by the school district, you must contact the San Diego County Office of Education at the address listed below: San Diego County Office of Education Attention Dan Puplava 6401 Linda Vista Road Room 505 San Diego, CA 92111-7399 (858) 292-3815 d. To change your beneficiary, you need to complete a new beneficiary form available at the San Diego County Office of Education. You may also obtain this form from your FBC representative. This form can be mailed directly to National Benefit Services, Inc. (Third Party Administrator) at the address indicated on the bottom of the Beneficiary form. 10. Am I required to complete the beneficiary designation form? No. If you are married, your beneficiary under the plan will automatically be your spouse. Otherwise, your beneficiary is automatically your estate. 11. What happens if I change jobs? a. If your new job is in the same district, no changes are required. b. If your new job is in another district that also participates in this program, you will be assigned a new account under that district. You will be eligible to take a distribution from your old account with your former district. c. If your new job is in a district that does not offer this program, you will not be able to continue deposits into the plan with your former district, and are eligible for a distribution. 12. What happens if I accept additional employment at a second district that does participate in the 3121 Plan? You must participate in each district’s 3121 Plan and will be subject to each district’s mandatory contributions. 13. What happens if I become a member of PERS or STRS? You will no longer be eligible to participate in the 3121 Plan. Contact the FBC office to determine options of transfer funds to PERS or STRS, or the eligibility of obtaining your funds. In accordance with the written policy upon becoming a permanent employee you are eligible for withdraw two (2) years after becoming a PERS or STRS member. 14. What happens when I leave service? You will no longer be eligible to participate in the 3121 Plan 15. What are my options when I am no longer eligible to participate? a. You may retain your funds in the 3121 Plan. b. You may transfer your 3121 account balance to PERS or STRS at any time if it is used to purchase state retirement credits. c. You may take an in-service withdrawal from your account balance if you have not made any contributions to the 3121 plan for 2 years and have a balance that is less than $5,000. 16. When am I eligible for a distribution? a. If you terminate from the school district or move to another district that does not participate in this program, you can apply for a distribution. b. If you retire, and are no longer working for your employer, you are eligible for a distribution. c. You may take an in-service withdrawal from your account balance once if you have not made any contributions to the 3121 plan for 2 years and have a balance that is less than $5,000. d. You may transfer your 3121 account balance to PERS or STRS at any time if it is used to purchase state retirement credits. 17. How do I apply for a distribution? a. You may obtain a “Distribution Form” from your district or the FBC office (858) 292-3815 b. You may also access the “Distribution Form” at www.fbcretire.com/3121 . 18. How long will it take to process my distribution? You qualify for a distribution three months after your district has established a termination date. 19. Am I eligible to participate in the Plan once I have taken a distribution? You may not participate in the Plan for 12 months following the date of your distribution. 20. Are there any transaction fees? A $10.00 fee will be deducted from your account for any distribution, transfer, or rollover. 21. Are distributions from the 3121 Plan subject to the premature distribution penalty tax? No, they are not subject to the 10% excise tax on distributions to individuals who have not attained 59 1/2. 22. Am I eligible to transfer my account to another 457(b) Plan offered by my employer? Yes. You may transfer your funds to another 457(b) Plan offered by your employer at any time. 23. How do I apply for a transfer? a. You may obtain a “Transfer Form’ from your district. b. You may also access the “Transfer Form” at www.fbcretire.com/3121 . If you have questions: Participant Call Center: 1-800-274-0503 press 5 Fax your questions to: (858) 569-7851 E mail questions to: www.fbcrtire.com/3121 Beneficiary Designation Form 1 Participant Information Participant Name Social Security Number Participant Mailing Address City, State, Zip Code Phone Number Married Single Participant Email Address Date of Birth Marital Status School District or Former School District Broker/Financial Advisor Name Broker/Financial Advisor Phone Number 2 Beneficiary Designation Information Option 1 I am NOT MARRIED and designate the following person(s) to receive any death benefits. I understand that if I marry, this designation becomes void one year after my marriage. Primary/Secondary Option 2 Name SSN Relationship % I am MARRIED and designate my spouse named below to receive ALL death benefits from the Plan. Spouse Name Spouse SSN Spouse Address If my spouse is not living, pay death benefits to: Primary/Secondary Option 3 Name Relationship % Relationship % I am MARRIED and designate the following person(s) to receive death benefits from the Plan (SPOUSAL CONSENT REQUIRED -- see below). Primary/Secondary 3 SSN Spousal Consent Name SSN (Required for Option 3) I consent to this designation which eliminates all or part of the benefits otherwise payable to me from the Plan if my spouse dies. Spouse’s Signature 4 Date Notary Public or Plan Administrator Date Participant Approval Participant Signature (Required) Date Form 403-208FBC (08/2015) 8523 S Redwood Rd, West Jordan, UT 84088 ● (800) 274 0503 ext 5 ● Fax (800) 597-8206 ● www.FBCretire.com GROSSMONT-CUYAMACA COMMUNTIY COLLEGE DISTRICT Date: June 13, 2012 To: All District Employees From: Vice Chancellor, Human Resources Subject: Drug Free Environment and Drug Prevention Program (Reference: Drug Free Schools and Communities Act, 20 U.S.C.) Section 1145g and 34 C.F.R. Section 86.1 et seq. Drug Free Workplace Act of 1988, 41 U.S.C. Section 702 It is the policy of Grossmont-Cuyamaca Community College District to maintain a work place environment free from the illegal use, possession, or distribution of controlled substances. The Governing Board originally adopted a policy relevant to this issue on May 9, 1989. The current Governing Board Policy (BP 3550), Drug Free Environment and Drug Prevention Program, issued June 13, 2012, is stated below: The Grossmont-Cuyamaca Community College District (District) is committed to providing its employees and students with a drug free workplace and campus environment. It emphasizes prevention and intervention through education. The District has health events, workshops and exhibits throughout the academic year promoting educational aspects of illicit drug use and alcohol abuse. The District provides students with prevention information and referrals for treatment for students with drug and alcohol issues. The District works closely with their college communities to share educational programs; and events to combat the use of illicit drugs and alcohol abuse by District students. Students may call or come to Student Health Services, Student Affairs Office or Counseling for additional information or help for illicit drug use or alcohol abuse. The range of health risks associated with the use of illicit drugs and the abuse of alcohol are varied. These health risks can include, but are not limited to: short term illnesses, long-term incurable diseases and/or can result in death. Prohibition of Drugs The unlawful manufacture, distribution, dispensing, possession or use of alcohol or any controlled substance is prohibited on District property, during District-sponsored field trips, activities or workshops, and in any facility or vehicle operated by the District. Anyone who has violated this policy is subject to disciplinary or other action in accordance with established procedures set forth in BP 5500 Standards of Student Conduct and the District’s employee handbooks; which may require satisfactory participation in an alcohol or drug abuse assistance or rehabilitation program. As a condition of employment, employees must notify the District within five (5) days of any conviction for violating a criminal drug statute while in the workplace. The District is required to inform any agencies that require this drug-free policy within ten (10) days after receiving notice of a workplace drug conviction. The Chancellor shall ensure that the District distributes annually to each student and employee the information required by the Drug-Free Schools and Communities Act Amendments of 1989 and complies with other requirements of the Act. GROSSMONT-CUYAMACA COMMUNITY COLLEGE DISTRCIT HUMAN RESOURCES PAYROLL INFORMATION FOR PART-TIME (NON-FACULTY) HOURLY EMPLOYEES A. Instructions for completing time sheets. Use black ink and print legibly. Print the day of the week opposite the corresponding date. List only actual hours worked. Any changes or corrections should be initialed, (If you do not receive a pre-printed time sheet, be sure to use the appropriate blank time sheet with your name, employee ID number, etc., clearly printed, and follow steps 2 – 4). 1. Print your name as it appears on your Social Security card when completing the top portion of the time sheet, and be sure your employee ID number is shown correctly. 2. If you work under more than one budget number, you must fill out a separate time sheet for each budget number. 3. When time sheets are due, fill in the hours you worked, your hourly rate of pay and sign the time sheet. Your supervisor is to verify correct budget number, rate of pay, initial holidays, if worked, and sign the time sheet. After your supervisor has signed it, take it to the Dean/Director/Manager for approval. All hourly time sheets are then submitted to the District Payroll Department. Note: Grossmont College Teaching Assistant (TA) time sheets are submitted to the Campus Business Office at Grossmont. 5. B. The due date for time sheets is the 10th of every month as indicated on the bottom of the time sheet. Late time sheets may not be paid until the following month. Paycheck Distribution: Grossmont College: Pick up your paycheck on the last working day of every month at the Campus Business Office. Checks picked up after the regular pay date will be available at the Campus Business Office, according to Campus Business Office hours. Paychecks remain at the Campus Business Office for thirty (30) days and then returned to the District Payroll Department for distribution. Cuyamaca College: Pick up your paycheck on the last working day of every month after 1:00 p.m., in the Cashier’s Office. Paychecks not picked up on the regular pay date will be available from 7:00 a.m. – 5:00 p.m., Monday through Thursday; Friday from 8:00 a.m. – 4:30 p.m. Unclaimed paychecks will be returned to the District Payroll Department after thirty (30) days. C. Release of Paychecks: Checks will not be released without a photo ID and/or student ID and another form of identification. Payday is the last working day of the month, however if the last working day of the month falls on a weekend or holiday, payday will normally be the preceding workday. If it is absolutely impossible for you to pick up your paycheck within five days after payday, contact the District Payroll department, in advance, to have your check mailed to you. Bring a self-addressed stamped envelop to the District Payroll department before the last working day of the month. Frequently Asked Questions for Employees About the New Health Insurance Marketplace 1. Q: What is the “Exchange” or “Marketplace” that I’ve been hearing about? A: The Exchange/Marketplace is a new health insurance marketplace in each state. The Marketplaces are established under the Healthcare Reform Act that was passed in 2010. The Marketplace is an on-line site where individuals and smaller employers may go to purchase health insurance coverage for 2014. 2. Q: How can I obtain more detailed information about the Marketplace? A: Visit the California Marketplace online at www.coveredca.com/ or call (888)975-1142. 3. Q: Why is the Marketplace being established? A: Under federal law, beginning January 1, 2014 individuals will be required to have minimum essential health coverage, or else be subject to a penalty. This is referred to as the “individual mandate.” The Marketplace is intended to help individuals meet the individual mandate requirement by providing another place to purchase coverage, and possibly qualify for federal assistance to do so. 4. Q: Do I have to purchase health coverage through the Marketplace? A: No. You may still obtain health coverage from other sources if you are eligible. To avoid the individual mandate penalty, you will want to confirm that the coverage you obtain provides “minimum essential coverage” under the rules. 5. Q: What are some possible other sources of coverage? A: Your employer, your spouse’s employer, Medicare (if eligible in your state), the individual market, etc. 6. Q: What if I am covered under my employer’s plan? Can I keep it? A: Yes. Most employer plans will qualify as the coverage required under the individual mandate requirements. You do not need to purchase coverage through the Marketplace in order to avoid the individual mandate penalty. You may, if you would like, however. 7. Q: Can I drop myself or my dependents from my group plan to purchase a plan through the Marketplace or outside of the Marketplace? A: Possibly. Employers and Marketplaces have very specific rules around enrollment and disenrollment. In general, both have an annual open enrollment period (which will usually be different) and permit special enrollments during the year based on events such as marriage or birth of a child. Although these rules are similar, they are not identical. In addition, determining when you can change an election outside the annual open enrollment period will be determined by IRS regulations and the terms of the group health plan. Generally, employees may not change an election unless the employee experiences a change in status permitted by the IRS and allowed by the group health plan. P:\ 8. Q: How do I know if I qualify for assistance to purchase my coverage through the Marketplace? A: Individuals who are not offered qualifying healthcare coverage through their employer may be eligible for government subsidies to help pay for health insurance premiums for plans purchased in the Marketplaces (based on income level and how many dependents you have). Generally, household income must be below 400% of the federal poverty level (which in 2013 is about $46,000 for an individual, or about $78,000 for a family of three), in addition to some other rules, in order to qualify. Whether you qualify will depend on what kind of coverage your employer offers. If your job-based coverage is considered affordable and meets minimum value requirements, you won't be able to get lower costs on premiums or out-of-pocket costs in the Marketplace. This is true no matter what your income and family size are. As state Marketplace sites are launched over the next months, you will be able to get details about a possible subsidy. 9. Q: Will my employer subsidize my health coverage if I purchase it through the Marketplace? A: Employers are not required to help you pay for coverage that you purchase through the Marketplace. With most employer-provided plans, the employer pays a portion of the premium cost. You should consider this when making decisions about where to obtain your health coverage. 10. Q: Will I be able to see my same doctor if I purchase coverage through the Marketplace instead of at work? A: Possibly. Insurance purchased through the Marketplace may have different provider networks. 11. Q: When will the Marketplace in my state be open for business? A: Open enrollment in the Marketplaces is scheduled to begin October 1, 2013, with coverage to generally become effective January 1, 2014. Please refer to the Marketplace in your state for further information. 12. Q: Do I have to enroll by January 1, 2014 in order to get coverage through the Marketplace? A: No. In this first year of Marketplace coverage, you may enroll until March 31, 2014. But if you enroll after December 15th of this year, your coverage will have an effective date that is later than January 1, 2014. To avoid not having coverage beginning January 1, 2014, and potentially incurring a penalty, you should enroll by December 15, 2013 if you wish to satisfy the individual mandate with coverage obtained through the Marketplace. 13. Q: Will my employer’s health benefits program be available for purchase through the Marketplace? A: Possibly, if your employer is considered to be a small employer under the rules, and has chosen to purchase its program for employees through the Marketplace. Generally, employers with over 100 employees, or in some states 50 employees, may not purchase their programs for employees through the Marketplace yet. Employers of any size may offer coverage through regular channels, however, just as they do today. New Health Insurance Marketplace Coverage Options and Your Health Coverage Form Approved OMB No. 1210-0149 H[SLUHV531 PART A: General Information ΈΙΖΟ͑ΜΖΪ͑ΡΒΣΥΤ͑ΠΗ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΔΒΣΖ͑ΝΒΨ͑ΥΒΜΖ͑ΖΗΗΖΔΥ͑ΚΟ͑ͣͥ͑͢͡͝ΥΙΖΣΖ͑ΨΚΝΝ͑ΓΖ͑Β͑ΟΖΨ͑ΨΒΪ͑ΥΠ͑ΓΦΪ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ:͑ΥΙΖ͑ΖΒΝΥΙ͑ ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅Π͑ΒΤΤΚΤΥ͑ΪΠΦ͑ΒΤ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΠΡΥΚΠΟΤ͑ΗΠΣ͑ΪΠΦ͑ΒΟΕ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͑͝ΥΙΚΤ͑ΟΠΥΚΔΖ͑ΡΣΠΧΚΕΖΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΥΙΖ͑ΟΖΨ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΖΞΡΝΠΪΞΖΟΥνΓΒΤΖΕ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟ ͑ What is the Health Insurance Marketplace? ΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΤ͑ΕΖΤΚΘΟΖΕ͑ΥΠ͑ΙΖΝΡ͑ΪΠΦ͑ΗΚΟΕ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΪΠΦΣ͑ΟΖΖΕΤ͑ΒΟΕ͑ΗΚΥΤ͑ΪΠΦΣ͑ΓΦΕΘΖΥ͑͟΅ΙΖ͑ ;ΒΣΜΖΥΡΝΒΔΖ͑ΠΗΗΖΣΤ͓͑ΠΟΖ͞ΤΥΠΡ͑ΤΙΠΡΡΚΟΘ͓͑ΥΠ͑ΗΚΟΕ͑ΒΟΕ͑ΔΠΞΡΒΣΖ͑ΡΣΚΧΒΥΖ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΠΡΥΚΠΟΤ͑͟ΊΠΦ͑ΞΒΪ͑ΒΝΤΠ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ ΗΠΣ͑Β͑ΟΖΨ͑ΜΚΟΕ͑ΠΗ͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑ΣΚΘΙΥ͑ΒΨΒΪ͑͟ΡΖΟ͑ΖΟΣΠΝΝΞΖΟΥ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΓΖΘΚΟΤ͑ΚΟ͑ΔΥΠΓΖΣ͑ͣͤ͑͢͡ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΤΥΒΣΥΚΟΘ͑ΒΤ͑ΖΒΣΝΪ͑ΒΤ͑ͻΒΟΦΒΣΪ͑͑ͣͥ͑͢͢͟͝͡ Can I Save Money on my Health Insurance Premiums in the Marketplace? ΊΠΦ͑ΞΒΪ͑ΦΒΝΚΗΪ͑ΥΠ͑ΤΒΧΖ͑ΞΠΟΖΪ͑ΒΟΕ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΓΦΥ͑ΠΟΝΪ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͝ΠΣ͑ ΠΗΗΖΣΤ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΕΠΖΤΟ͘Υ͑ΞΖΖΥ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟΅ΙΖ͑ΤΒΧΚΟΘΤ͑ΠΟ͑ΪΠΦΣ͑ΡΣΖΞΚΦΞ͑ΥΙΒΥ͑ΪΠΦ͘ΣΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑ΕΖΡΖΟΕΤ͑ΠΟ͑ ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͟ Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? ΊΖΤ͑͟ͺΗ͑ΪΠΦ͑ΙΒΧΖ͑ΒΟ͑ΠΗΗΖΣ͑ΠΗ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΗΣΠΞ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͝ΪΠΦ͑ΨΚΝΝ͑ΟΠΥ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΞΒΪ͑ΨΚΤΙ͑ΥΠ͑ΖΟΣΠΝΝ͑ΚΟ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͘Τ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑͟ΠΨΖΧΖΣ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΠΣ͑Β͑ΣΖΕΦΔΥΚΠΟ͑ΚΟ͑ΔΖΣΥΒΚΟ͑ΔΠΤΥ͞ΤΙΒΣΚΟΘ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΒΥ͑ΒΝΝ͑ΠΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟ͺΗ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑Β͑ΡΝΒΟ͑ΗΣΠΞ͑ΪΠΦΣ͑ ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΨΠΦΝΕ͑ΔΠΧΖΣ͑ΪΠΦ͙͑ΒΟΕ͑ΟΠΥ͑ΒΟΪ͑ΠΥΙΖΣ͑ΞΖΞΓΖΣΤ͑ΠΗ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͚͑ΚΤ͑ΞΠΣΖ͑ΥΙΒΟ͖͑ͪͦ͑͟ΠΗ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ ΚΟΔΠΞΖ͑ΗΠΣ͑ΥΙΖ͑ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΥΙΖ͑ΔΠΧΖΣΒΘΖ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΡΣΠΧΚΕΖΤ͑ΕΠΖΤ͑ΟΠΥ͑ΞΖΖΥ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͓͑ΤΥΒΟΕΒΣΕ͑ΤΖΥ͑ΓΪ͑ΥΙΖ͑ ͲΗΗΠΣΕΒΓΝΖ͑ʹΒΣΖ͑ͲΔΥ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑͟͢ ͑ ͿΠΥΖͫ͑ͺΗ͑ΪΠΦ͑ΡΦΣΔΙΒΤΖ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟΤΥΖΒΕ͑ΠΗ͑ΒΔΔΖΡΥΚΟΘ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ ΖΞΡΝΠΪΖΣ͑͝ΥΙΖΟ͑ΪΠΦ͑ΞΒΪ͑ΝΠΤΖ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͙͑ΚΗ͑ΒΟΪ͚͑ΥΠ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͟ͲΝΤΠ͑͝ΥΙΚΤ͑ΖΞΡΝΠΪΖΣ͑ ΔΠΟΥΣΚΓΦΥΚΠΟ͑͞ΒΤ͑ΨΖΝΝ͑ΒΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΖ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͑ΥΠ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͞ΚΤ͑ΠΗΥΖΟ͑ΖΩΔΝΦΕΖΕ͑ΗΣΠΞ͑ΚΟΔΠΞΖ͑ΗΠΣ͑ ͷΖΕΖΣΒΝ͑ΒΟΕ͑΄ΥΒΥΖ͑ΚΟΔΠΞΖ͑ΥΒΩ͑ΡΦΣΡΠΤΖΤ͑͟ΊΠΦΣ͑ΡΒΪΞΖΟΥΤ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΣΖ͑ΞΒΕΖ͑ΠΟ͑ΒΟ͑ΒΗΥΖΣ͞ ΥΒΩ͑ΓΒΤΚΤ͑͟ ͑ How Can I Get More Information? ͷΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΡΝΖΒΤΖ͑ΔΙΖΔΜ͑ΪΠΦΣ͑ΤΦΞΞΒΣΪ͑ΡΝΒΟ͑ΕΖΤΔΣΚΡΥΚΠΟ͑ΠΣ͑ Jenny Aquino, District Benefits Technician, [email protected] , (619)644-7643 ΔΠΟΥΒΔΥ͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͟ ͑ ΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΔΒΟ͑ΙΖΝΡ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΡΥΚΠΟΤ͑͝ΚΟΔΝΦΕΚΟΘ͑ΪΠΦΣ͑ΖΝΚΘΚΓΚΝΚΥΪ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑ ;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΚΥΤ͑ΔΠΤΥ͑͟ΝΖΒΤΖ͑ΧΚΤΚΥ͑ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΗΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͝ΚΟΔΝΦΕΚΟΘ͑ΒΟ͑ΠΟΝΚΟΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ ΚΟΤΦΣΒΟΔΖ͑ΔΠΧΖΣΒΘΖ͑ΒΟΕ͑ΔΠΟΥΒΔΥ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΗΠΣ͑Β͑ΖΒΝΥΙ͑ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟ͑ΪΠΦΣ͑ΒΣΖΒ͑͟ ͑͢ͲΟ͑ ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͑ ͓ΞΚΟΚΞΦΞ͑ ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑ ΚΗ͑ ΥΙΖ͑ΡΝΒΟ͘Τ͑ΤΙΒΣΖ͑ΠΗ͑ ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑ ΓΪ͑ ΥΙΖ͑ΡΝΒΟ͑ΚΤ͑ ΟΠ͑ ΝΖΤΤ͑ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑ΠΗ͑ ΤΦΔΙ͑ΔΠΤΥΤ͑͟ PART B: Information About Health Coverage Offered by Your Employer ΅ΙΚΤ͑ΤΖΔΥΚΠΟ͑ΔΠΟΥΒΚΟΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΒΟΪ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΔΠΞΡΝΖΥΖ͑ΒΟ͑ ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ΪΠΦ͑ΨΚΝΝ͑ΓΖ͑ΒΤΜΖΕ͑ΥΠ͑ΡΣΠΧΚΕΖ͑ΥΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͟΅ΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΚΤ͑ΟΦΞΓΖΣΖΕ͑ ΥΠ͑ΔΠΣΣΖΤΡΠΟΕ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑͟ 3. Employer name 4. Employer Identification Number (EIN) 956006652 Grossmont-Cuyamaca Community College District 5. Employer address 6. Employer phone number (619)644-7639 8800 Grossmont College Drive 7. City 8. State CA El Cajon 9. ZIP code 92020 10. Who can we contact about employee health coverage at this job? Jenny Aquino, District Benefits Technician 11. Phone number (if different from above) ͑ (619)644-7643 12. Email address [email protected] ΖΣΖ͑ΚΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΥΙΚΤ͑ΖΞΡΝΠΪΖΣͫ͑ x ͲΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΨΖ͑ΠΗΗΖΣ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΠͫ͑ ͲΝΝ͑ΖΞΡΝΠΪΖΖΤ͑͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑ ͑ ✔ ͑ ͑ Full-Time͑ Contract Academic, Classified, Supervisor, and Confidential employees. Classified employees who are contracted 50% or greater. ͑ ΄ΠΞΖ͑ΖΞΡΝΠΪΖΖΤ͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑͑ ͑ ͑ ✔ ͑ ͑ Legal spouse, legal dependent child(ren), step child(ren), state certified domestic partner, legal dependent of an official ͑ dependent, and certified disabled dependent children. x ΈΚΥΙ͑ΣΖΤΡΖΔΥ͑ΥΠ͑ΕΖΡΖΟΕΖΟΥΤͫ͑ ΈΖ͑ΕΠ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟ͶΝΚΘΚΓΝΖ͑ΕΖΡΖΟΕΖΟΥΤ͑ΒΣΖͫ͑ ͑ ͑ ✔ ͑ ͑ ΈΖ͑ΕΠ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟ ͑ ͺΗ͑ΔΙΖΔΜΖΕ͑͝ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΞΖΖΥΤ͑ΥΙΖ͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͑͝ΒΟΕ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΚΤ͑ΚΟΥΖΟΕΖΕ͑ ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΓΒΤΖΕ͑ΠΟ͑ΖΞΡΝΠΪΖΖ͑ΨΒΘΖΤ͑͟ ͑ ͛͛͑ ͶΧΖΟ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΚΟΥΖΟΕΤ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ ΕΚΤΔΠΦΟΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΨΚΝΝ͑ΦΤΖ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͝ΒΝΠΟΘ͑ΨΚΥΙ͑ΠΥΙΖΣ͑ΗΒΔΥΠΣΤ͑͝ ΥΠ͑ΕΖΥΖΣΞΚΟΖ͑ΨΙΖΥΙΖΣ͑ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ͺΗ͑͝ΗΠΣ͑ΖΩΒΞΡΝΖ͑͝ΪΠΦΣ͑ΨΒΘΖΤ͑ΧΒΣΪ͑ΗΣΠΞ͑ ΨΖΖΜ͑ΥΠ͑ΨΖΖΜ͙͑ΡΖΣΙΒΡΤ͑ΪΠΦ͑ΒΣΖ͑ΒΟ͑ΙΠΦΣΝΪ͑ΖΞΡΝΠΪΖΖ͑ΠΣ͑ΪΠΦ͑ΨΠΣΜ͑ΠΟ͑Β͑ΔΠΞΞΚΤΤΚΠΟ͑ΓΒΤΚΤ͚͑͝ΚΗ͑ΪΠΦ͑ΒΣΖ͑ΟΖΨΝΪ͑ ΖΞΡΝΠΪΖΕ͑ΞΚΕ͞ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΪΠΦ͑ΙΒΧΖ͑ΠΥΙΖΣ͑ΚΟΔΠΞΖ͑ΝΠΤΤΖΤ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΦΒΝΚΗΪ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ ͑ ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΤΙΠΡ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ ΨΚΝΝ͑ΘΦΚΕΖ͑ΪΠΦ͑ΥΙΣΠΦΘΙ͑ΥΙΖ ΡΣΠΔΖΤΤ͑͟ΖΣΖ͘Τ͑ΥΙΖ͑ ΖΞΡΝΠΪΖΣ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΪΠΦ͘ΝΝ͑ΖΟΥΖΣ͑ΨΙΖΟ͑ΪΠΦ͑ΧΚΤΚΥ͑ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΥΠ͑ΗΚΟΕ͑ΠΦΥ͑ΚΗ͑ΪΠΦ͑ΔΒΟ͑ΘΖΥ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΠ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞΤ͑͟ ͑ TO: All Non Bargaining Unit Employees FROM: Tim Corcoran, Vice Chancellor of Human Resources RE: Notice of Healthy Workplace Healthy Family Act of 2014 Paid Sick Leave (AB1522) Important Notice regarding new law affecting Non-Bargaining Unit Employees On September 10, 2014, Governor Brown signed into law the Healthy Workplaces, Healthy Families Act of 2014 (known as Assembly Bill 1522 or AB1522). This bill provides paid sick leave days to workers who do not currently earn this benefit. This bill specifically requires employers to provide paid sick leave to employees who work 30 or more days within a year from commencement of employment. Employees will earn a minimum of one hour of paid sick leave for every 30 hours worked. California’s AB1522 law went into effect on January 1, 2015. Entitlements of the paid sick leave for employees will go into effect beginning July 1, 2015. Eligible employees will begin receiving sick accruals based on the number of hours worked in the preceding pay period. The group of employees affected by AB1522 are non-bargaining unit employees. This category includes the following: substitutes, student workers, Federal Work Study, NANCE, Professional Expert, etc. The district will implement the following entitlements and policies beginning July 1, 2015. ENTITLEMENT of PAID SICK LEAVE Sick Plan Year – Begins July 1 – June 30 (same as fiscal year) Eligible Employees – Only Employees solely hired in a non-bargaining unit position will be eligible for this sick leave plan. Note: Bargaining Unit employees with an additional non-bargaining position will not be eligible for this plan. Eligibility for the plan – Employees will be eligible for the sick leave plan 30 days from hire date. Existing employees hired prior to June 1, 2015 will be eligible on July 1, 2015 Employees hired after June 1, 2015 will be eligible 30 days from their hire date. Accrual Rate – Paid sick leave accrues at the rate of one hour per every 30 hours worked and recorded as paid time. Example: Timesheet hours recorded as 30 hours of paid time will result in 1 hour of sick leave accrual. Example: Timesheet hours recorded as 40 hours of paid time will result in 1.33 hours of sick leave accrual (40/30=1.33) Accrual Maximum – Employees will be eligible for a maximum accrual of 48 hours per plan year. Vice Chancellor of Human Resources 8800 Grossmont College Drive, El Cajon, CA 92020-1799 Fax 619-644-7919 Phone 619-644-7572 Accrual Carryover Maximum – Employees can carryover a maximum of 48 hours from one plan year to the next plan year. Rate of pay for sick leave – Employees will be paid at the current rate of pay for any sick leave usage. First Accrual and Payroll period – Eligible employees will have the first accrual posted from the hours reported based on the timesheet period in which the plan is in effect. Accrual will be based on the hours submitted to payroll for hours worked on July 1, 2015 – July 14, 2015. All subsequent accruals will be based on hours worked relevant to the pay period submitted o Subsequent accrual for hours worked during July 15, 2015 – August 14, 2015 USAGE Usage of plan – Employees may begin using accrued sick leave on the 90th calendar day of employment. Usage of sick leave – Employees may use their paid sick leave for the following: Themselves or a family member for the diagnosis, care or treatment of an existing health condition or preventative care. Family member means the following: o Child biological, adopted, or foster child, stepchild, legal ward or child to whom the employee stand in loco parentis, regardless of the child’s age or dependence status o Biological adoptive, or foster parent, stepparent or legal guardian of an employee or the employee’s spouse or registered domestic partner, or a period who stood in loco parentis when the employee was a minor child. o A spouse, registered domestic partner, grandparent, grandchild, or sibling. Specified purposes for an employee who is a victim of domestic violence, sexual assault or stalking. Yearly Limit on usage – Employees will be limited to a maximum of 24 hours of paid sick leave per plan year. Daily limit on usage – Employees will be required to use the sick leave in the following increments of time so long as the employee has the available balance available. Minimum of 2 hours o Employees can use a minimum of 2 hours of paid sick leave up to scheduled hours. o Employees using paid sick time will not be able to use the sick absence for any time less than 2 hours per paid time off request such as 1 ½ hour, 1 hour, or ½ hour Limit on available balance – In addition to the yearly limit, employees will not be able to use paid sick leave when there is no sick leave balance available. Neither the district nor the department may advance paid sick leave to an eligible employee of this plan. How to use the benefit If the use of sick leave is foreseeable, employees must provide their supervisor with advance notice. If the need for the leave is unforeseeable, the employee shall provide notice as soon as practicable and report their absence to their supervisor. It will be the responsibility of the employee to enter and record their absence on their timesheet. The employee’s supervisor may enter this absence on the behalf of the employee when notified. If the absence is not recorded on their timesheet, the absence will not be considered as paid sick leave. Permanent positions Non-bargaining unit employees offered a permanent bargaining unit position will not have this sick leave balance transferred to the new bargaining unit position. The employee will be offered sick leave based on Education Code and benefits as listed in the collective bargaining agreements. Separation from employment No Payoffs – This sick leave plan is not compensable wages at the time of termination. Employees with a balance of this sick leave plan will not have any sick leave balance paid out at the time of separation from the district. Transfers of sick leave – This sick leave plan is not transferrable. Balance Available – the sick leave balance will be available to the employee for one year from the date of separation with the district. If the employee is rehired within one year into a non-bargaining position they will have previously accrued and unused paid sick leave balances reinstated and available for use upon re-employment. After one year of separation the unused and accrued sick leave will be deleted from the employee’s previous sick leave balance. Pension Plan and Sick Leave Service Credit – CalPERS will not recognize this paid time off as creditable service. Employees who are also members of CalPERS will not have this paid time reported to CalPERS for service during employment or reported as unused sick leave at the time of retirement. Therefore, no retirement contributions will be withheld from the employee’s paycheck for this sick leave plan. Protection from Retaliation Provisions of the law prohibit an employer from denying an employee the right to use the paid sick leave, discharging, threatening to discharge, demoting, suspending, or in any manner discriminating against an employee. There is a rebuttable presumption of unlawful retaliation if the employer acts in a manner described above within 30 days of the employee’s request for leave or other protected activity. If you have any questions or concerns related to this new sick leave, please call the payroll general number at 619-644-7902
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