WESTON PUBLIC SCHOOLS – ANNUAL OPEN ENROLLMENT FORM
PAYROLL/BENEFITS CHANGE FORM - 2016/2017 SCHOOL YEAR
CERTIFIED STAFF - WTA
NAME______________________________________________BIRTHDATE ________________________
MAIDEN NAME - _________________________________________
ADDRESS ______________________________________________________________
CITY/STATE/ZIP CODE _________________________________________________
TELEPHONE# ____________________________
IS THIS A NEW ADDRESS: YES ____NO_____ IF YES REFER TO WESTON’S WEBSITE FOR AN
ADDRESS/NAME CHANGE FORM – CHANGE WILL NOT BE ACCEPTED OR PROCESSED
WITHOUT THE FORM.
** Please calculate my 2016/2017 salary on the following basis of:
** Please have my check/direct deposit advice sent to the:
______(22 pays)
_____(26 pays)
E.S. _____ 3-5 INTERM._____ M.S. _____
H.S. _____
C.O. ____
Please check the following that applies: If you are interested in changing/starting/discontinuing any benefit
listed below, please refer to the Weston Website under staff area then forms for all payroll related forms.
CHANGES WILL NOT BE ACCEPTED OR PROCESSED WITHOUT THE APPROPRIATE FORM.
_____ I wish to START Health Insurance
______ I wish to START Dental Insurance
_____ I wish to CONTINUE Health Insurance
______ I wish to CONTINUE Dental Insurance
_____ Please DISCONTINUE my Health Insurance
______ Please DISCONTINUE my Dental Insurance
_____ I am NOT INTERESTED in having Health Coverage
______ I am NOT INTERESTED in having Dental Coverage
_____ I wish to START Flex Spending Acct
______ I wish to CONTINUE my Flex Spending Acct
______ Please DISCONTINUE my Flex Spending Acct
_____ I am NOT INTERESTED in having Flex Spending
*** I will be retiring as of 6/14/2016 – Continue Insurance: ______ YES
______ NO
*** I will be resigning as of 6/14/2016 – Continue Insurance: ______ YES
______ NO
**Please contact Marisa Forchione at 1409**
**Please contact Marisa Forchione at 1409**
Certified Staff will contribute according to their respective contracts and will contribute as identified in their Flexible Spending
Account Enrollment Form.
Please check the following that applies: If you are interested in changing/starting/discontinuing any benefit
listed below, please refer to the Weston Website under staff area then forms for all payroll related forms.
CHANGES WILL NOT BE ACCEPTED OR PROCESSED WITHOUT THE APPROPRIATE FORM.
DIRECT DEPOST
START ______ CHANGE ______ CONTINUE________ DISCONTINUE _________
N/A _______
TAX SHELTER 403B
START ______ CHANGE ______
N/A _______
TRI-TOWN CREDIT UNION
CONTINUE________ DISCONTINUE _________
START ______ CHANGE ______
EMPLOYEE FUNDING TO START ______ CHANGE ______
YOUR H.S.A BANK ACCOUNT
CONTINUE________ DISCONTINUE _______
N/A ____
CONTINUE_____ DISCONTINUE _________
N/A ______
Note: TEACHERS’ RETIREMENT FOR CERTIFIED STAFF (.5 OR HIGHER) IS AUTOMATICALLY DEDUCTED FROM 20 PAYS.
WESTON TEACHERS’ ASSOCIATION DUES
______ ACTIVE MEMBER
________ AGENCY FEE
**FAILURE TO MAKE A SELECTION WILL RESULT IN AGENCY FEE**
Association Dues Certified Staff: (WTA, CEA, NEA) Total cost of $804.00 will be deducted at the rate of
$40.20 per paycheck. This amount is subject to change for active and agency fee members. Agency fee
will not be known until December. Agency fee payments are collected through automatic deductions from
January through April.
SIGNATURE __________________________________________ DATE _______________________
BENEFITS PAYROLL DEDUCTION AUTHORIZATION FORM 2016-2017 – CERTIFIED STAFF
1.
MEDICAL AND DENTAL INSURANCE
CHECK ONE PLAN & COST SHARE OPTION THAT APPLIES
$2000/$4000 H.S.A PLAN



EMPLOYEE
EMPLOYEE + 1
FAMILY
COST
SHARE
DELTA DENTAL
COVERAGE
$81.46
$146.52
$221.75



EMPLOYEE
EMPLOYEE + 1
FAMILY
COST
SHARE
COMBINED
COST SHARE
FOR 20 PAYS
$3.51
$7.04
$10.67
$84.97
$153.57
$232.42
EMPLOYER H.S.A. CONTRIBUTION IS 50% OF PRORATED ANNUAL DEDUCTIBLE
SINGLE = $1,000.00
2 PERSON = $2,000.00 FAMILY = $2,000.00
(1) (3) BELOW
PER PAY EMPLOYEE COVER REMAINING DEDUCTIBLE H.S.A. CONTRIBUTION BASED ON 20 PAYS
SINGLE = $50.00
2 PERSON = $100.00
FAMILY = $100.00
(2) (3) BELOW
PER PAY EMPLOYEE FUND TO FEDERAL MAX BASED ON 20 PAYS
SINGLE = $117.50 2 PERSON = $237.50 FAMILY = $237.50
(2) (3) BELOW
1 - Weston's contributions equal 50% of the Prorated Annual Deductible of $2,000 for Single and
$4,000 for Family. Participant must be an ACTIVE employee and enrolled in the HSA
plan each month to qualify for contribution. (Note: Annualized contribution equals $1,000 for
Single and $2,000 for Family)
2 – ILLUSTRATIVE - Participant is not required to make an HSA contribution. Participants
may choose to fund any amount up to the maximum allowed by the IRS guidelines. If participant
chooses to contribute to the HSA, contributions for 2016 can not exceed $3,350 for Single and
$6,750 for Family (Participants can contribute an additional $2,350 for Single and $4,750
Family). Participant must be enrolled in the HSA plan to make a qualified contribution.
Participants 55 years or older may be eligible for an additional $1,000 "catch up" contribution
per year
3 - To be eligible for qualified contributions to an HSA participants may not have other health
coverage that is not a High Deductible Health Plan. Participants that have other High Deductible
Health Plan coverage should seek advice as to maximum contributions allowed by IRS guidelines.
SIGNATURE ________________________________________________
DATE __________________________
** TAX FORMS ARE AVAILABLE ON THE WESTON WEBSITE UNDER STAFF AREA THEN FORMS****
PLEASE RETURN ORIGINAL TO MARISA FORCHIONE NO LATER THAN JUNE 10, 2016.
IF YOU HAVE ANY QUESTIONS, PLEASE EMAIL AT [email protected]**