FEDERATION OF INSTRUCTIONAL SUPPORT PERSONNEL

Health Insurance Waiver, 2008-2009

Pursuant to the 2005-2011 collective bargaining agreement between the St. Lawrence-Lewis BOCES and the St. Lawrence-Lewis BOCES Federation of Instructional Support Personnel, Article IX, Section 10, subsection A,

I, the undersigned, verify the following:

• 1. I am a unit member of the St. Lawrence-Lewis BOCES Federation of Instructional Support Personnel;

• 2. I am eligible for health insurance coverage from another source outside the St Lawrence-Lewis School District Employees Medical Plan;

• 3. I elect not to be covered by the health insurance plan provided by the St. Lawrence-Lewis BOCES;

• 4. I understand that I may only reapply for coverage through St. Lawrence-Lewis BOCES if my circumstances change due to a qualifying event (e.g., death, layoff or disability of spouse, or divorce);

• 5. In exchange for this waiver, I am requesting the sum of one thousand dollars ($1,000) from the St. Lawrence-Lewis BOCES.

______________  __________    _______________ _______________                                                                                                                                                           

Signature                Date                Printed Name           SS# (last 4 digits)

This form must be submitted to the BOCES Purchasing Agent, St. Lawrence-Lewis BOCES Central Office, PO Box 231, 139 State Street Road, Canton, NY, 13617.

Deadline for submission: May 1, 2008.  (Unit members newly hired September 1, 2008 through January 31, 2009 may elect this waiver upon hire.)