Part-time Classified, Adjunct Lecturer, Classified Temporary or Substitute Employees
2020-21 Offer of Health Insurance Coverage
As a classified part-time, adjunct lecturer and classified temporary and substitute employee of the
West Kern Community College District for the 2020-21 school year, you are being given the opportunity
to purchase health insurance for you and your eligible children. A summary of the available insurance
plan is included in this packet. If you should choose to enroll, you will be responsible for making
monthly premium payments to the District’s Human Resources Department.
To request enrollment on this plan, you must submit the following items to the District’s Human
Resources Department no later than two weeks from your date of hire or the end of the Open
Enrollment period. No late enrollments will be accepted.
• A
completed and signed SISC III enrollment form
• Proof of eligibility for dependent children (birth certificates/adoption paperwork)
• First month’s premium payment in the form of a check or money order in the applicable amount
noted belo
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2020-21 Monthly Rates –Two Tier Anchor Bronze Plan
o Employee Only: $569.00
o 2 Party: $893.00
o Family: $893.00
Subsequent monthly payments are due in full by the 25
th
of the month prior to the coverage month. If
payment is not received by the 1
st
of the coverage month, your coverage will be terminated. If your
employment status ends at any time during the plan year, coverage will be terminated the first of the
month following. No reinstatements will be allowed.
If you fail to provide the items required for enrollment within two weeks of your hire date, you and your
dependent children will not be allowed to enroll until the next Open Enrollment Period. Members who
enroll during the Open Enrollment Period will become effective October 1
st
of the same year.
Part-time Classified, Adjunct Lecturer, Classified Temporary or Substitute Employees
2020-21 Declination of Health Insurance
I have read and understand the above notification. I understand that if I decline coverage or fail to
provide the items required for enrollment within two weeks of my hire date or at the end of the Open
Enrollment period, I will not be able to enroll in coverage until the District’s next Open Enrollment
period.
My signature below indicates that I am declining health insurance coverage for the 2020-21 plan year
(10/1/20 – 9/30/2021).
Print Name:_______________________________________________________
Signature:_________________________________________________________
Date:______________________________ A#:__________________________________
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signature
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