Rates & Documents

Rates & Documents

Interactive forms allow you to open the form and type directly onto the form using your keyboard. After you have finished entering your information, you must then print the form (you can only save a blank copy of the form) and submit it as requested.

Forms
Forms
Brief Description

Adult Child Notice and Enrollment Form

 

Notification and enrollment form for adult dependent children in available health plans. Additional premium required.

2017 Current Employee with Adult Child Notice

Notification and enrollment form for adult dependent children in available health plans. Additional premium required.

2017 Retiree with Adult Child Notice

Notification and enrollment form for adult dependent children in available health plans. Additional premium required.

Authorization For Release Of Health Information (HIPAA) Form
 

Interactive form allowing person authorized by employee to address benefits concerns.

Birth of Child-Instructions and Newborn Status Change Form
 

Birth of a Child-Instructions and Interactive Newborn Staus Change Form.

Deletion Form
 

Interactive form used to remove/delete dependents and/or change participation levels (Restrictions Apply)

Domestic Partner Enrollment Forms
 

Interactive Insurance Enrollment Forms and information for adding a domestic partner and dependents

Disenrollment Statement - Domestic Partner

Interactive Insurance Disenrollment Form for deleting a domestic partner and dependents

EAP Formal Referral Form Interactive Referral Form used by Administrators/Supervisors to request EAP Assistance

 

Evidence of Insurability Application - Life Insurance
 
 
 
 

Application used to request enhancement of Life Insurance.

 

FMLA Application-Administrative and Non-Instructional Personnel

 

 

 

 

-FMLA Application-Instructional Personnel

 

 

 

 

FMLA Certification - Employee

FMLA Certification - Family Member

FMLA Certification - Exigency Military

FMLA Certification - Current Military

FMLA Certification - Veteran Military

Interactive Application used to request Family Medical Leave - Administrative and Non-Instructional Personnel. When submitting an application for FMLA the applicable certification form must be completed and sent directly to the Leaves Department.

 

 

Interactive Application used to request Family Medical Leave - Administrative and Non-Instructional Personnel When submitting an application for FMLA the applicable certification form must be completed and sent directly to the Leaves DepartmentThere are five (5) different certification forms, depending on which leave is being selected.? All certification forms must be completed by physician or practitioner and employee.
 
 
 
 
 
 
 

Instructional Transfer Request Form Form used to request transfer for instructional employees.
Leave of Absence Request
 
Interactive Application for Board Approved Leave of Absence .
Medco Mail-Order Prescription Form
 
Form used to order prescriptions via mail-order service from Medco.
Medco Mail-Order Prescription Refill Form
 
Form used to order refill of prescriptions via mail-order service from Medco.

Opt-Out | Dental

Opt-Out | Medical

Opt-Out | Vision

Interactive forms used to request a waiver of Medical, Dental and Vision Insurance Coverage for School Board Employee.
 
 
 
MetLife Absence Reporting Guide
 
Instructions for filing a (MetLife) disability claim by telephone
Mutual Of Omaha Life Insurance Portability Request Form Interactive form used to continue term life insurance within 31 days of employee's termination.
Supplemental Deletion Form Interactive form utilized for cancelation of supplemental insurance.
Vision - Humana CompBenefits Out of Network Reimbursement Form Interactive form utilized for reimbursement of Out-of-Network Vision Care Claims


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Rate Information
Rate Information
Brief Description

COBRA Health, Kids' Plans, Dental and Vision Rates for 2017
 

Cost of COBRA Health, Kids' Plans, Dental & Vision Insurance for the 2017 calendar year (includes 2% Administrative Fee).

Employee Rates 2017
 

Cost of Insurance Plans for the 2017 calendar year

Leave Rates 2017
 

Cost of Insurance Plans for the 2017 calendar year

Retiree Rates 2017

Cost of Health, Kids' Plans, Dental and Vision Insurance for Retirees for the 2017 calendar year.

COBRA Health, Kids' Plans, Dental and Vision Rates for 2016

Cost of COBRA Health, Kids' Plans, Dental & Vision Insurance for the 2016 calendar year (includes 2% Administrative Fee).

Leave Rates 2016
 

Cost of Insurance Plans for the 2016 calendar year

Employee Rates 2016
 

Cost of Insurance Plans for the 2016 calendar year

Retiree Health, Kids' Plans, Dental and Vision Rates for 2016

Cost of Health, Kids' Plans, Dental and Vision Insurance for Retirees for the 2016 calendar year.


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Documents and Notices
Documents and Notices
Brief Description

Change in Status
 

Guidelines to follow to change your status outside of Open Enrollment.

COBRA
 
 

Definition of COBRA and information regarding rights and responsibilities for continuation of coverage.

COBRA Administrators Information
 
 

Listing of administrators of COBRA for health, dental and vision providers to School Board employees.

FMLA Rights & Responsibilities - English 2013
 

FMLA Rights & Responsibilities - Spanish 2013

Employee Rights and Responsibilities Under the Family and Medical Leave Act.

Derechos Y Responsabilidades Del Empleado Bajo La Ley De Ausencia Familiar Y Medica

Notice - Medicaid and the Children's Health Insurance Program (CHIP) 2012

Notice regarding premium assistance programs for children's health insurance premiums.

Notice of Privacy Practices- EAP
 

HIPAA Notice of Privacy Practices Related to The School Board of Broward County's Employee Assistance Program

Notice of Privacy Practices - Health Plans
 

HIPAA Notice of Privacy Practices Related to The School Board of Broward County's Health Plans

Notice - Prescription Drug Coverage and Medicare 2015
 

Notice regarding current prescription drug coverage under SBBC and options under Medicare's prescription drug coverage.

Update Dependent & Beneficiary Information
 
 
 
 
 
 

Instructions on updating dependent and beneficiary information on Employee Self-Service (ESS). Dependents can only be added or deleted from health, dental and vision plans during Open Enrollment or by a qualifying event. Click on Library of Benefits for specific information.

Vacation & Sick Leave Payout (Tab on ESS)
 
 
Instructions on how to view estimated vacation and sick leave payouts on ESS. Contact the payroll person at your location regarding any discrepancies.


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