Beneflex Insurance Enrollment & Change Form Logo

  • Welcome to Pinellas County Schools Beneflex Insurance 2024 Enrollment & Change Form

  • Pinellas County Schools Beneflex Insurance 2024 Enrollment & Change Form Information

  • THIS IS FOR 2024 NEW HIRE BENEFITS ONLY. IF YOUR BENEFITS WILL TAKE EFFECT 2025, PLEASE GO TO WWW.PCSB.ORG/NEW-HIRE FOR A LINK TO THE 2025 ENROLLMENT LINK.

     

    Newly Hired

    Welcome to Pinellas County Schools! As a newly benefit-eligible employee, this is your opportunity to enroll in the benefit plans of your choice.

    For a summary of our benefit plans, please review our Benefits At A Glance.

    • Effective Date:  Benefits are effective the first day of the month following 60 days of employment in a benefit eligible status. 

    • Benefit Election Deadline:  You have 31 days from your new hire date to enroll in benefits.  If you are late, you will have to wait until the next Annual Enrollment (mid-October) to apply for your benefit for the new calendar year, unless you have a qualifying family status change. 

    • Refusal of Health Plan Election: If you do not purchase medical insurance, you may receive up to $75 per pay period credit toward the purchase of eligible supplemental benefits. For more details on what options are available with your credits, view the No Health Flyer.

    • Insurance Payroll Deductions:  Your deductions are based upon 20 pay periods during the year. You do not have payroll insurance deductions during the summer.  If your coverage is effective after January 1, you may have a premium adjustment to pay for the summer coverage.  You will be notified by the benefits team of this payroll adjustment amount and what pay periods it will be collected.

    Contact:  Questions?  Contact the benefits team 588-6197 for assistance.

  • Welcome to Pinellas County Schools 2024 Beneflex Insurance Enrollment & Change Form

     

     

    If you are experiencing an IRS recognized family status change, you must complete this form and submit within 31 days of the life event. Changes are effective the first of the month following event date and receipt of application, unless otherwise stated.

     

    PATIENT PROTECTION AND AFFORDABLE CARE ACT INFORMATION


    Starting in 2019, most Americans are no longer required to purchase health insurance coverage or pay a penalty. The medical plan offered by PCS does meet the affordability and coverage requirements.

    If you cannot afford to enroll your spouse and/or child(ren) in a PCS medical plan, there may be cost-effective options through the Marketplace and/or Florida KidCare. If you choose to opt out of PCS coverage and buy insurance in the Marketplace you will:

    o Not receive a contribution from PCS towards the cost of your Marketplace coverage
    o Not be eligible for a government premium subsidy to help pay for your Marketplace coverage
    o If you receive a premium subsidy, and you are insurance benefit eligible you may be responsible to pay the premium subsidy back to the IRS

      

    Below you can click the images to view Pinellas County Schools Benefit and New Hire Guides to assist in your decision as you navigate through this form.

     

     New Hire Decision Guide:                                                                                          Employee Benefit Guide:

  • Image-188
  • Image-187

  • PCS New Hire Orientation Video

  • New Hire REQUIRED SUPPORTING DOCUMENTATION (If you are enrolling members in insurance coverage)

    • Spouse
    • COPY of marriage certificate or the first page of your most recent tax return with your spouse’s name
    • Child(ren)

     

    • Disabled Child(ren)
    • COPY of birth certificate or adoption documentation. Court ordered legal custody documentation.
    • COPY of birth certificate AND COPY of most recent tax return confirming child is your dependent.

      

  • FAMILY STATUS CHANGE LIFE EVENT

    REQUIRED SUPPORTING DOCUMENTATION – Contact Risk Management if you are unable to provide documentation with application submission. Birth certificates for newborns may be sent after enrollment &change form is received, if unavailable at time of submission.

    • Marriage
    • COPY of marriage certificate
    • Birth/Adoption
    • COPY of Birth Certificate(s) or adoption documentation or Court ordered Legal Custody documentation
    • Divorce
    • COPY of first and last page of final divorce decree
    • Loss of Coverage
    • Documentation from employer or insurance provider indicating WHO lost coverage, WHEN coverage endedand WHY coverage ended. Loss of coverage must be because you are no longer eligible versus voluntarycancellation of coverage or for non payment
    • Obtained Coverage
    • Documentation that you or your dependent has obtained other coverage.Documentation should include WHO has obtained coverage and the effective date of coverage
    • Other
    • Please contact Risk Management for required documentation.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Employee Information

  •  / /
  •  - -
  •  / /

  • Dependent Information

  •  

    Dependent Verification

    If you are requesting enrollment of a spouse or dependent child, please confirm that all of your dependents meet the eligibility requirements and provide us their social security numbers. This is required to comply with Centers for Medicare and Medicaid Services (CMS) Medicare Secondary Payer program.

    MEDICAL, DENTAL, VISION COVERAGE

    Eligible dependents include :

    • Your legally married spouse
    • Your natural born child, step-child, foster child, legally adopted child, child placed in your custody for adoption, or child for whom you have been appointed permanent legal guardian, whose age is less than the limiting age.
    • A newborn child of a covered dependent may be covered while the parent is an eligible dependent under the plan up to the limiting age of 18 months.
    • Grandchildren may also be covered if he or she is dependent upon you for support and you have court-ordered “legal custody” - Documentation will
      be required.

    Age Limits:

    • For medical, dental, and vision coverage, your eligible children may be covered up to the end of the calendar year in which they attain age 26. No
      additional dependent financial or student status is required.
    • Handicapped children may be covered beyond limiting age, if proof of handicapped status is provided to Risk Management within 31 days of the limiting age. See Beneflex guide for full details.
    • Children for whom you had permanent legal guardianship or foster children - typically once they turn 18 are no longer eligible.

    LIFE INSURANCE COVERAGE

    Eligible dependents include :

    • Your legally married spouse, up to age 70
    • Dependent children include your unmarried natural born child, step-child, foster child, legally adopted child, child proposed for adoption, or child for whom you have been appointed legal guardian, whose age is less than the limiting age. Your eligible dependent will be covered to the end of the calendar year in which he or she turned 26.
    • Grandchildren may only be covered if you have court-ordered “legal custody.”

     

    By clicking that you are adding or deleting a dependent, you verify that you understand the dependent eligibility criteria above. If a dependent is listed that does not meet this criteria, you may be responsible for reimbursing the insurance carrier for all claims and repaying the district for its premium contribution for up to 12 months. Enrolling dependents who are not eligible under PCS plans, may also subject you to disciplinary action. In addition to our internal policies, the Florida Department of Financial Services views this activity as fraud and considers it prosecutable under the law.

  •  - -

  • New Hire REQUIRED SUPPORTING DOCUMENTATION (If you are enrolling members in insurance coverage)

    • Spouse
    • COPY of marriage certificate or the first page of your most recent tax return with your spouse’s name
    • Child(ren)

     

    • Disabled Child(ren)
    • COPY of birth certificate or adoption documentation. Court ordered legal custody documentation.
    • COPY of birth certificate AND COPY of most recent tax return confirming child is your dependent.

  • FAMILY STATUS CHANGE LIFE EVENT

    REQUIRED SUPPORTING DOCUMENTATION – Contact Risk Management if you are unable to provide documentation with application submission. Birth certificates for newborns may be sent after enrollment &change form is received, if unavailable at time of submission.

    • Marriage
    • COPY of marriage certificate
    • Birth/Adoption
    • COPY of Birth Certificate(s) or adoption documentation or Court ordered Legal Custody documentation
    • Divorce
    • COPY of first and last page of final divorce decree
    • Loss of Coverage
    • Documentation from employer or insurance provider indicating WHO lost coverage, WHEN coverage endedand WHY coverage ended. Loss of coverage must be because you are no longer eligible versus voluntarycancellation of coverage or for non payment
    • Obtained Coverage
    • Documentation that you or your dependent has obtained other coverage.Documentation should include WHO has obtained coverage and the effective date of coverage
    • Other
    • Please contact Risk Management for required documentation.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  •  - -

  • New Hire REQUIRED SUPPORTING DOCUMENTATION (If you are enrolling members in insurance coverage)

    • Spouse
    • COPY of marriage certificate or the first page of your most recent tax return with your spouse’s name
    • Child(ren)

     

    • Disabled Child(ren)
    • COPY of birth certificate or adoption documentation. Court ordered legal custody documentation.
    • COPY of birth certificate AND COPY of most recent tax return confirming child is your dependent.

  • FAMILY STATUS CHANGE LIFE EVENT

    REQUIRED SUPPORTING DOCUMENTATION – Contact Risk Management if you are unable to provide documentation with application submission. Birth certificates for newborns may be sent after enrollment &change form is received, if unavailable at time of submission.

    • Marriage
    • COPY of marriage certificate
    • Birth/Adoption
    • COPY of Birth Certificate(s) or adoption documentation or Court ordered Legal Custody documentation
    • Divorce
    • COPY of first and last page of final divorce decree
    • Loss of Coverage
    • Documentation from employer or insurance provider indicating WHO lost coverage, WHEN coverage endedand WHY coverage ended. Loss of coverage must be because you are no longer eligible versus voluntarycancellation of coverage or for non payment
    • Obtained Coverage
    • Documentation that you or your dependent has obtained other coverage.Documentation should include WHO has obtained coverage and the effective date of coverage
    • Other
    • Please contact Risk Management for required documentation.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  •  - -

  • New Hire REQUIRED SUPPORTING DOCUMENTATION (If you are enrolling members in insurance coverage)

    • Spouse
    • COPY of marriage certificate or the first page of your most recent tax return with your spouse’s name
    • Child(ren)

     

    • Disabled Child(ren)
    • COPY of birth certificate or adoption documentation. Court ordered legal custody documentation.
    • COPY of birth certificate AND COPY of most recent tax return confirming child is your dependent.

  • FAMILY STATUS CHANGE LIFE EVENT

    REQUIRED SUPPORTING DOCUMENTATION – Contact Risk Management if you are unable to provide documentation with application submission. Birth certificates for newborns may be sent after enrollment &change form is received, if unavailable at time of submission.

    • Marriage
    • COPY of marriage certificate
    • Birth/Adoption
    • COPY of Birth Certificate(s) or adoption documentation or Court ordered Legal Custody documentation
    • Divorce
    • COPY of first and last page of final divorce decree
    • Loss of Coverage
    • Documentation from employer or insurance provider indicating WHO lost coverage, WHEN coverage endedand WHY coverage ended. Loss of coverage must be because you are no longer eligible versus voluntarycancellation of coverage or for non payment
    • Obtained Coverage
    • Documentation that you or your dependent has obtained other coverage.Documentation should include WHO has obtained coverage and the effective date of coverage
    • Other
    • Please contact Risk Management for required documentation.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  •  - -

  • New Hire REQUIRED SUPPORTING DOCUMENTATION (If you are enrolling members in insurance coverage)

    • Spouse
    • COPY of marriage certificate or the first page of your most recent tax return with your spouse’s name
    • Child(ren)

     

    • Disabled Child(ren)
    • COPY of birth certificate or adoption documentation. Court ordered legal custody documentation.
    • COPY of birth certificate AND COPY of most recent tax return confirming child is your dependent.

  • FAMILY STATUS CHANGE LIFE EVENT

    REQUIRED SUPPORTING DOCUMENTATION – Contact Risk Management if you are unable to provide documentation with application submission. Birth certificates for newborns may be sent after enrollment &change form is received, if unavailable at time of submission.

    • Marriage
    • COPY of marriage certificate
    • Birth/Adoption
    • COPY of Birth Certificate(s) or adoption documentation or Court ordered Legal Custody documentation
    • Divorce
    • COPY of first and last page of final divorce decree
    • Loss of Coverage
    • Documentation from employer or insurance provider indicating WHO lost coverage, WHEN coverage endedand WHY coverage ended. Loss of coverage must be because you are no longer eligible versus voluntarycancellation of coverage or for non payment
    • Obtained Coverage
    • Documentation that you or your dependent has obtained other coverage.Documentation should include WHO has obtained coverage and the effective date of coverage
    • Other
    • Please contact Risk Management for required documentation.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  •  - -

  • New Hire REQUIRED SUPPORTING DOCUMENTATION (If you are enrolling members in insurance coverage)

    • Spouse
    • COPY of marriage certificate or the first page of your most recent tax return with your spouse’s name
    • Child(ren)

     

    • Disabled Child(ren)
    • COPY of birth certificate or adoption documentation. Court ordered legal custody documentation.
    • COPY of birth certificate AND COPY of most recent tax return confirming child is your dependent.

  • FAMILY STATUS CHANGE LIFE EVENT

    REQUIRED SUPPORTING DOCUMENTATION – Contact Risk Management if you are unable to provide documentation with application submission. Birth certificates for newborns may be sent after enrollment &change form is received, if unavailable at time of submission.

    • Marriage
    • COPY of marriage certificate
    • Birth/Adoption
    • COPY of Birth Certificate(s) or adoption documentation or Court ordered Legal Custody documentation
    • Divorce
    • COPY of first and last page of final divorce decree
    • Loss of Coverage
    • Documentation from employer or insurance provider indicating WHO lost coverage, WHEN coverage endedand WHY coverage ended. Loss of coverage must be because you are no longer eligible versus voluntarycancellation of coverage or for non payment
    • Obtained Coverage
    • Documentation that you or your dependent has obtained other coverage.Documentation should include WHO has obtained coverage and the effective date of coverage
    • Other
    • Please contact Risk Management for required documentation.
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • If more than 5 dependents please contact Risk Management at Risk-Benefits@PCS.org.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Medical Benefit Enrollment

  • REFUSAL OF HEALTH COVERAGE

  • Clear
  •  - -

  • If you do not purchase medical insurance, you may receive up to a $75 per-pay-period credit toward the purchase of eligible supplement benefits: "No Health" Board Contribution.

    The $75 per-pay-period credit applies to the following benefits:

    • Dental
    • Eye
    • Metlife Hospital Income Plan
    • Accidental Death & Dismemberment 
    • Disability
    • Healthcare Flexible Spending

    Look for the at the top of the page for those benefits that apply.

  • Image-309

  • *Look forthe at the top of the page for benefits that apply.

  • Please select the following dependents that will be covered under this plan:
     -->       
      -->       
      -->       
     -->       
      -->       

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Dental Benefit Enrollment

  • Benefit Qualifies for $75 Contribution Credit

  • Please select the following dependents that will be covered under this plan:
     -->       
      -->       
      -->       
     -->       
      -->       

  • *Warning: Your Total Pay-Period Deduction is over the $75 Per-Pay Board Contribution Credit. Any amount over $75.00 will be deducted per pay period.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Vision Benefit Enrollment

  • Benefit Qualifies for $75 Contribution Credit

  • *Vision is free at no cost for Employee (Self).

  • Please select the following dependents that will be covered under this plan:
     -->       
      -->       
      -->       
     -->       
      -->       

  • *Warning: Your Total Pay-Period Deduction is over the $75 Per-Pay Board Contribution Credit. Any amount over $75.00 will be deducted per pay period.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Metlife Hospital Income Plan (HIP) Benefit Enrollment

  • Benefit Qualifies for $75 Contribution Credit

  • Please select the following dependents that will be covered under this plan:
     -->       
      -->       
      -->       
     -->       
      -->       

  • *Warning: Your Total Pay-Period Deduction is over the $75 Per-Pay Board Contribution Credit. Any amount over $75.00 will be deducted per pay period.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Accidental Death & Dismemberment Benefit Enrollment

  • Benefit Qualifies for $75 Contribution Credit

  • *Warning: Your Total Pay-Period Deduction is over the $75 Per-Pay Board Contribution Credit. Any amount over $75.00 will be deducted per pay period.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Disability Benefit Enrollment

    Disability Plan Enrollment and Change Form will be generated and reviewed by Risk Managment prior to approval. Refer to the enrollment materials provided when completing the following:

  • Benefit Qualifies for $75 Contribution Credit

  •  / /
  •  - -
  •  / /

  • Based on your plan selection, using your annual base salary and your monthly disability benefit amount decision, please enter the Rate Per-Pay Deductions for 20 Pay Periods in the box below. This can be determined by the chart below following the row of your selection. 

  • Image-726
  • Image-727
  • Image-728
  • Image-729
  • Image-730
  • Image-731

  • Acknowledgement - by initialing and signing below, I wish to make the choices indicated on this form. I authorize deductions from my wages to cover my contribution, if required, toward the cost of insurance. I understand that my deduction amount will change if my coverage or costs change.

    Initials: * ------ I understand I am responsible for paying any premium due for which the Payroll Department cannot make a regularly scheduled deduction.
    Initials: * ------ I understand that the insurance applied for contains exclusions and limitations.

  • Clear

  • *Warning: Your Total Pay-Period Deduction is over the $75 Per-Pay Board Contribution Credit. Any amount over $75.00 will be deducted per pay period.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Family Term Life Benefit Enrollment

  • *Warning: Your Total Pay-Period Deduction is over the $75 Per-Pay Board Contribution Credit. Any amount over $75.00 will be deducted per pay period.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Healthcare Flexible Spending Benefit Enrollment

  • Benefit Qualifies for $75 Contribution Credit

    *The "$75 Board Contribution Credit" only applies up to $25 max. Anything over this amount will be deducted.

  • *Warning: Your Total Pay-Period Deduction is over the $75 Per-Pay Board Contribution Credit. Any amount over $75.00 will be deducted per pay period.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Dependent Flexible Spending Benefit Enrollment

    *This benefit is for daycare/other care for children under the age of 13 years old.

  • *Warning: Your Total Pay-Period Deduction is over the $75 Per-Pay Board Contribution Credit. Any amount over $75.00 will be deducted per pay period.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Employee Optional Term Life Benefit Enrollment

    *Employee Election over $250,000 Will require online application subject to medical approval.

  • *Warning: Your Total Pay-Period Deduction is over the $75 Per-Pay Board Contribution Credit. Any amount over $75.00 will be deducted per pay period.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Spouse Optional Term Life Benefit Enrollment

    *Spouse election over $30,000 - Will require online application subject to medical approval.
  •  / /

  • *WARNING - Spouse Term Life Insurance election amount requested is over $100,000 and/or over Employee Term Life Insurance election + Guarantee amount based on annual salary. Please correct this by electing a lower amount.

     

  • *Warning: Your Total Pay-Period Deduction is over the $75 Per-Pay Board Contribution Credit. Any amount over $75.00 will be deducted per pay period.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Children Optional Term Life Benefit Enrollment

  • *Warning: Your Total Pay-Period Deduction is over the $75 Per-Pay Board Contribution Credit. Any amount over $75.00 will be deducted per pay period.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  • Beneficiary Information

    Board Paid Life Insurance and AD & D Beneficiary(ies) - Required Information

  • Your primary beneficiary is first in line to receive your death benefit. If the primary beneficiary dies before you, a secondary or contingent beneficiary is the next in line. Percentages must equal 100%.

    Note: The Life Insurance Beneficiary(ies) will also serve as beneficiary to any funds [vacation pay-out, sick time, if applicable] deposited to a PCS Special Pay plan upon your retirement or separation if you do not have a living spouse and have not designated a primary beneficiary. If you wish to name a separate beneficiary, you may contact our Retirement Team at 727-588-6214.

     

  •  

  • Note: If the primary beneficiary dies before you, a secondary or contingent beneficiary is the next in line. Percentages must equal 100%.

  •  

  • Pinellas County School District Beneflex Insurance Enrollment and Change Form Submission Agreement

  • By signing below I agree to the following:

     

    PRE-TAX PREMIUM PLAN - (if selected) I elect to have premiums for my medical, dental, vision, HIP, disability, and flexible spending account(s) deducted from my pay on a pre-tax basis through IRS section 125 cafeteria plan. Premiums will continue unless noted otherwise via annual enrollment or within 31 days of a qualified life event. 

    INSURANCE PREMIUMS - Premiums are due in advance, therefore deductions begin the month before the effective date of coverage. Deductions are taken over 20 pay periods. I understand that I pay for coverage over a 10 month period, but I am covered for the entire year. Premium for summer coverage may be an additional amount owed upon initial enrollment or if a change is made during the year.

    COBRA INFORMATION - I acknowledge information concerning my rights under the Consolidated Budget Reconciliation Act (COBRA) has been made available to me (www.pcsb.org/cobra) and I understand if married, it is my responsibility to share this information with my spouse and/or dependents.

    WORKERS COMPENSATION - I have received information about my rights and responsibilities regarding work related illness or injuries under Workers Compensation. I understand that 1) it is my responsibility to report a work related accident within 24 hours, when possible; 2) unauthorized absences and treatment will not be covered and 3) Pinellas County Schools has the right to choose the medical providers who will treat me. Full details are available online: www.pcsb.org/workerscomp. 

  • Clear
  •  - -

  • *Warning: Your Total Pay-Period Deduction is over the $75 Per-Pay Board Contribution Credit. Any amount over $75.00 will be deducted per pay period.

  • Beneficiary Change Only

    Complete Top Employee Information Section, Life Insurance Beneficiary section, and Signature and Date

    Click Next or use the tabs above to get to the applicable form.

  •  
  • Should be Empty: