MEDICAL STIPEND FOR ASSOCIATE FACULTY: The District provides up to $1,000.00 of
medical reimbursement per semester for reimbursement of employee-incurred health benefit costs to
all part-time hourly academic employees who are currently employed by the District and complete a
40% or more of a full-time load in the District. The reimbursement periods for the fall and spring
semesters are July 1 through December 31 and January 1 through June 30.
The stipend shall be used to reimburse associate faculty who qualify for reimbursement under these provisions
for premium costs only from enrollment in any HMO, PPO, or indemnity health plan licensed and registered by
either the California Department of Insurance or the California Department of Corporations.
Employees wishing to be reimbursed for medical expenses under this article must initiate the request on the
Associate Faculty Medical Reimbursement Request Form. The employee must furnish documentation from
either the insurance company or employer showing that the employee purchasing health insurance during
the instructional period for which the employee was otherwise not eligible for reimbursement from any
other source. This request is to be submitted only to the Payroll Office for approval and processing of the
The reimbursement request must be received by the Payroll Office by:
for the period covering July through December;
b) June 15
for the period covering January through June.
If you meet the requirements above and you wish to participate in the program, complete the Associate
Faculty Medical Reimbursement Request Form along with the required documentation. Submit the
completed form to the Payroll Office for approval and processing.
EMPLOYEE NAME: (please print)________________________________
ID#: _________________
MAILING ADDRESS: ___________________________________________________________________________________________
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: ________________
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: $________________
Payroll Office Signature: ______________________________
REV 01/2017
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