BRCC Adjunct/Part-Time Hires
Other
LCTCS Employment
and
Patient Protection & Affordable Care Act
(This
is
for Part-time BRCC employees
ONLY
.)
NAME
(As
it
appears on Social Security Card) EMPLOYEE ID NUMBER EXPECTED START
DATE
Section 1: Employment with LCTCS Colleges
or
Board Office
Louisiana
Community
and
Technical Colleges System (LCTCS) Colleges
Baton Rouge Community College Nonhshore Technical Community College
Bossier Parish Community College Nonhwest Louisiana Technical College
Central Louisiana Technical College Nunez Community College
Delgado Community College River Parishes Community College
Aetcher Technical Community College South Central Louisiana Community College
Louisiana Delta Community College South Louisiana Community College
SOWELA
Technical Community College
I. Do you already hold a position at BRCC outside
of
th
is adjunct position?
__
YES
__
NO
~
If
YES, is your current position full-time
or
pan-time/adjunct? _
PT
FT
~
Please provide current
position:--------------------
2. Do you hold or are you being considered for another position at the LCTCS Board Office
or
any other
LCTCS College?
__
YES
__
NO
);;;>
If
YES, please provide the name(s) or the
LCfCS
institution(s) and Job title(s)
Institution/College
Name Position/Job Title
Retirement
• Are you currently enrolled
in
any State
of
LA retirement system (TRSL, LASERS, ORP)?
_Yes
_ No
• If yes,
whi
ch system? (circle one) TRSL LASERS ORP Other
------
• Are you a
Return·to-Work
Retiree?
__
Yes
__
No
Section 2: Patient Protection & Affordable
Care
Act
Confirmation
of
Current
Health
Coverage. Please circle "Yes"
or
"No"
for each question.
• Do you currently have health coverage through employment outside
of
BRCC? Yes No
• Do you currently have health coverage through a spouse, parent,
or
family member? Y cs No
• Do you currently have health coverage as a retiree? Yes No
• Do you currently have health coverage through employment with any LCTCS College
(outside
ofBRCC)
the LCTCS Board Office
or
the State
of
Louisiana? Yes No
• Do you currently have health coverage through employment with BRCC? Yes No
_
If
YES,
re
garding your current
co
~
crage,
please select one of the following options.
I wish
to
have
my
current coverage: retained changed
__
_:
cancelled
Ir
NO
please choose A
or
B
in
the
box below .
.
If
}:OU
answered
NO
to
the
above·stated guestion
1
l!lease choose
one
Ol!tion
b}:
si.:nin~:;
below
the
chosen Ol!tion:
A.
lr
you
An:
not
currently
coven:d
by
a
LCfCS
or
BRCC·offen:d
B.
lr
you
arc
not
currently
covered
by
a
LCfCS
or
BRCC-offcn:d
health
plan
and
you
an:
NOT
interested
in
being
covered
by
D
health
plan
and
you
ARE
interested
in
bcin&
covcn:d
by
o
BRCC-
BRCC-offen:d
health
plan,
please
sign
the
following
declarulion
.
offered
health
plAn,
please
sign
the
following
declaration.
By
signing
here.
I
decline
applying
for
bclllth
coveruge
for
myself
And
I
am
interested
in
understanding
"·
hcther
I
qooliry
ror
health
my
eligible
dependents
tbruush
my
employment
with
BRCC,
and
I
covrrogc.
By
signing
here,
I
ccrtiry
that
all
inCormation
I
h11ve
certify
that
all
information
I
have
provided
is true
and
corn:d.
provided
is true
and
corn:d,
and
I
undc:rstllnd
that
BRCC
is
hcn:hy
offering
me
hcalth
coveruge,
if
I
qualify
. I
understand
that
I
must
con
tad
BRCC
HR
to
aeelx
for
£!!V~[J!I!:
wjlbin
30
daxs
of
mx
start
date.
Contact
BRCC
HR:
225-216-8268
or
hrbrcc@mxbrcc.edu.
Signature or Part-time Employee' Adjunct
Signature or Part·time Employee' Adjunct
Date:
Date:
HR/0411912016
