ELCA Pension and Other Benefits Program
Change of Call Report
Important Information
Portico Benefit Services must receive this form within 60 days of the change of call. Incomplete or illegible forms
may be returned. (If returned to you, your new benefits will not be activated until Portico receives the correctly completed form.)
A
Your Personal Information
Legal Name (First)
MI
Last
Email Address
Address (if changing)
Date of Birth (mm/dd/yyyy)
City
Member ID
XXX – XX –
Social Security Number
State
ZIP Code
ELCA Synod Affiliation
(
)
Home Phone (if changing)
(
)
Work Phone (if changing) (
)
Cell Phone
Are you serving in Word and Sacrament ministry under appointment by the synod bishop? No
Date of Marriage
Is your spouse/ESGP separately enrolled in the ELCA benefits program?
B
Yes
–
–
Spouse’s/ESGP’s Social Security Number
Legal Name of Spouse, if Married or Separated, or of ESGP* (First, MI, Last)
Spouse’s/ESGP’s Date of Birth
(
)
Fax (if changing)
Yes
No
On Leave From Call
I am on leave from call. Please contact the Portico Customer Care Center regarding your benefits coverage. You don’t
need to complete this form.
C
New Call Information (If you have multiple employers, contact the Portico Customer Care Center.)
Name of Sponsoring Employer (Required)
(
)
Employer’s Phone
Address (Required)
State
City
ZIP Code
Your Job Title or Occupation
This is a (check [4] one)
Call Contract
Has your call or contract for services been issued by an ELCA entity
(a congregation, synod council, or ELCA church council)?
Yes No
Is this an interim position?
Yes No
How many hours are you scheduled to work?
_____ Hours per week
How many months are you scheduled to work?
_____ Months per year
* An eligible same-gender partner (ESGP) is an individual who satisfies Portico’s same-gender partnership requirements as attested on a completed Affidavit of
Partnership filed with Portico.
Continued on page 2
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C
New Call Information (If you have multiple employers, contact the Portico Customer Care Center.) – Continued
Effective Dates
Please complete the following effective dates regarding your sponsorship. You may need to ask your employer to provide some of
the following information. These dates determine the effective date of coverage under the ELCA benefits program.
a. Date of hire
(MM/DD/YYYY)
b. Effective date of salary
(MM/DD/YYYY)
c. Date sponsorship in ELCA benefits program began
(MM/DD/YYYY)
Annual Defined Compensation
1. Annual gross base salary1 (don’t include housing allowance here) $________________________
2. Social Security tax allowance2 (if you receive it) $________________________
3. Total of (1) + (2) $________________________
4. Required for clergy: Housing (check [4] applicable box) Amount designated as housing allowance (if housing is not provided) or
30% of line 3 (if housing is provided)
$________________________
5. Household furnishings and utilities allowances (for clergy only)
(if housing is provided and these allowances are paid to you)
$________________________
6. Annual defined compensation3 = Total of (3) + (4) + (5) $________________________
D
ELCA Health Benefits Plan Coverage Election
1. Elect one of the following options for coverage under the ELCA Health Benefits Plan
(check [4] one and list those to be covered in Section D2 or complete Section D3 if waiving health coverage.)
Member only
Member and spouse/ESGP
Member and child(ren)
Member, spouse/ESGP, and child(ren)
Waive health coverage
To waive coverage, you (or your dependents) must have other valid health coverage — group health coverage or
individual coverage purchased through a health insurance exchange for which you received a premium tax credit
(subsidy). (Complete Sections D3 and D4.)
2.List yourself and all eligible dependents to age 26 who will have ELCA health coverage. (Attach a separate sheet of paper
if more space is needed.)
Is individual enrolled in
Medicare Parts A/B?
Yes
No
Member’s Name
Spouse’s/ESGP’s Name
–
–
Social Security Number
Gender Birth Date
Child’s Name –
–
Social Security Number
Gender Birth Date
Child’s Name
–
–
Social Security Number
Gender Birth Date
1.Include base salary, before pretax benefit contributions are deducted
(pretax contributions to the ELCA Retirement Plan, health care or
dependent care flexible spending accounts, health savings accounts, or
transportation reimbursement accounts). This does not include a car
allowance or reimbursement of expenses by your employer.
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(F or M)
Yes
No
Yes
No
Yes
No
(mm/dd/yyyy)
2. The Social Security tax allowance may be paid to reimburse pastors for a
portion of self-employed Social Security taxes. Contact the IRS for help
estimating the amount.
3.This number determines the total amount on which contributions for
your health, retirement, and disability benefits are calculated.
Continued on page 3
D
ELCA Health Benefits Plan Coverage Election – Continued
Typically, you keep the same health benefit option you selected for the plan year if you change call. Exceptions:
• If this is your first sponsored call of the calendar year, Portico will contact you after receiving this form. After you talk
with a Portico representative, sign in to myPortico to select your health benefit option and any optional benefits you may be
eligible for as a result of your new call.
• If you previously waived ELCA health benefits and now want to enroll, please contact the Portico Customer Care Center.
3.List yourself and all eligible dependents for whom ELCA health coverage is waived. (Attach a separate sheet of paper if
more space is needed.)
Member’s Name
–
–
Spouse’s/ESGP’s Name
Social Security Number
Gender (F or M)
Birth Date
(mm/dd/yyyy)
Child’s Name
–
–
Social Security Number
Gender Birth Date
Child’s Name
–
–
Social Security Number
Gender Birth Date
Note: If you and your eligible dependents have other valid health coverage and waive ELCA health coverage, you can activate ELCA coverage on a later date.
If ELCA coverage is activated more than 60 days following termination of the other valid coverage, you and your dependents will be subject to a 90-day waiting
period for ELCA health coverage. If you waive coverage and Portico learns you do not have other valid health coverage, all ELCA benefits will be inactivated.
4.If you are waiving, or reactivating ELCA health coverage, provide the following required information. To waive ELCA
health coverage, you are required to have other valid health coverage. To reactivate ELCA health coverage, you must have had
valid health coverage and have been covered by it within the last 60 days in order to avoid a 90-day wait for ELCA health coverage.
Family members covered under other insurance (check [4] one):
Entire Family
Member Only
Spouse Only
Child(ren) Only
Spouse and Child(ren)
Employer-provided coverage:
Name of Employer Providing Coverage (Required)
ID Number (Required)
Name of Health Insurance Company
Type of Coverage:
Medical and Hospital
Prescription Drug
Group Number (Required)
(
Phone
)
Dental
Subsidized exchange coverage:
Name of State Exchange (Required)
ID Number (Required)
Name of Health Insurance Company (Required)
Type of Coverage:
E
Medical and Hospital
Prescription Drug
(
)
Exchange Phone
Dental
ELCA Flexible Benefits Plan
When you change or start a new call, you may be eligible to enroll in the Flexible Benefits Plan or change your FSA election for the
remainder of the plan year.
•If you have 31 days or fewer between eligible employers, you must continue your FSA with the same annual election you
chose prior to changing employment (unless you have a qualifying election change event that allows you to change your election).
•If you have more than 31 days between eligible employers, your old FSA election ends and you can make a new election for
the remainder of the calendar year.
To enroll in the Flexible Benefits Plan or make a new election, sign in to myPortico within 60 days of your new employment date.
Your election will be effective the first of the month following your election.
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Continued on page 4
F
Signature of Member
I agree to participate in the ELCA benefits program as indicated on this form. If I need additional information, I know I can
contact Portico.
Additionally, I acknowledge:
•I must pay the cost of benefits elected if I’m not sponsored in the ELCA benefits program by an eligible employer.
•I understand if this form is not returned to Portico within 60 days of the date I meet the program’s eligibility requirements,
I will be subject to a 90-day waiting period for health coverage and an 18-month pre-existing condition exclusion period for
disability benefits coverage unless special or open enrollment applies.
Signature of Member (Required)
G
Date (mm/dd/yYyy)
Signature of Sponsoring Employer
Employer Retirement Contribution (Required)
a. Total employer retirement contribution (required for pastors and rostered laypersons). We understand our employer
retirement contribution must be at least 10% of this employee’s defined compensation. This does not include employee pretax
retirement or housing equity contribution amounts.
Total employer retirement contribution ___________% of the member’s annual total compensation
b. Housing equity contribution agreement (optional)
We will remit $___________ per month to the pastor’s ELCA Retirement Plan account for housing equity contributions.
We recognize that housing equity contributions are a voluntary contribution from us and not a deduction from the pastor’s
paycheck. Housing equity contributions are in addition to compensation that is designated as housing allowance.
Note: The Internal Revenue Service sets annual limits for retirement plan contributions. Contact our Customer Care Center
for more details.
We hereby declare the employee named here works at least 15 hours per week six or more months a year and is eligible to
participate in the ELCA benefits program. The program includes health (unless waived), retirement, disability, and life
insurance benefits. We agree to be bound by the terms and conditions of the plan documents of these benefit plans and we agree
to sponsor this employee in the ELCA benefits program.
Name of Sponsoring Employer (Required)
Employer ID
Date You Started Sponsoring this Employee (MM/DD/YYYY)
Signature of Employer Representative (Required) (MM/DD/yyyy)
Title
(
)
Daytime Phone
1. Employer Identification Number (EIN): ___ ___ – ___ ___ ___ ___ ___ ___ ___
Total number of employees (full- and part-time) under your EIN: ________
2. Employee Count (used for Medicare reporting requirements): (check [4] one)
We have never had 20 or more employees.
We have had 20 or more employees in at least 20 or more weeks during the current or preceding year.
We currently have fewer than 20 employees. However, we had 20 or more employees in at least 20 or more weeks during the
current or preceding year: ______________ (MM/DD/yyyy in which the number of employees changed to fewer than 20).
Return this completed form and any requested documentation to the Portico Customer Care Center. Incomplete or
illegible forms may be returned, which will delay your benefits enrollment.
Portico Benefit Services
800 Marquette Ave., Ste. 1050 / Minneapolis, MN 55402-2892
800.352.2876 / 612.333.7651 / F 612.334.5399
[email protected] / PorticoBenefits.org
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