ASSOCIATE FACULTY
MEDICAL REIMBURSEMENT REQUEST FORM
EMPLOYEE NAME: (please print)________________________________
ID#: _________________
_______
__
MAILING ADDRESS: ___________________________________________________________________________________________
E-MAIL:______________________________
TELEPHONE:____________________________
*
Checks will be mailed to mailing address noted above.*
Please check reimbursement request period
_____July 1 through December 31
Employed in Fall Semester
Form due in the Payroll Office by Dec. 15
_____January 1 through June 30
Employed in Spring Semester
Form due in the Payroll Office by Jun. 15
PART A: PROGRAM ELIGIBILITY (to be completed by employee)
Check ALL that apply:
___ I have completed at least 40% of a full-time load this semester (as per Ed Code 87861(b)).
___ I am currently enrolled and I am paying premiums to the following medical plan:
The medical plan Group Number is: ____________ Date first enrolled in this plan: _________
The premium costs are $_________ per ___month ___quarter ___year
___ I am aware that per Education Code 87861 (a), benefits do not include vision or dental coverage.
___
I am aware that per Ed Code 87864, no part-time faculty member or dependents whose premiums for health insurance are
paid through an employer other than a community college district is eligible to participate in this
program established pursuant to this article.
___
In addition to my adjunct employment at College of the Redwoods, I also am employed by another California community college
district (Yes or No?) If
yes, district name:
________________________________________
___ I understand that the District will reimburse me pursuant to CRFO/RCCD contract provisions & in accordance
with Education Code provisions.
___
Documentation from either the insurance company or employer
Note: All documents must have your name and the name of medical plan.
Amount submitted for reimbursement consideration: $__________ (Maximum reimbursement of $1,000.00)
Employee Signature: ________________________________________
Date: ________________
PART B:
ELIGIBILITY VERIFICATION (to be completed by the Payroll Office ONLY)
___Request for Program participation is approved. All of the required program criteria have been met and VERIFIED.
Required proof of medical plan enrollment and premium payments are attached to this form.
Amount approved for reimbursement: $________________
Date:______________
Payroll Office Signature: ______________________________
REV 01/2017
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