PT Faculty>Reimbercement
APPLICATION FOR PAYMENT FROM HEALTH INSURANCE REIMBURSEMENT FUND FOR PCC PART-TIME FACULTY
PDF vesion here>>
Word vesion here>>
To be eligible for reimbursement, you must:
• return this completed application, along with proof of payment of insurance (we need it
every term), to the PCC Faculty Federation by fax at 503-977-4198; intercampus mail at SY ST 01;
or postal mail at PO Box 19389 Portland, OR 97280-0389
Deadline: December 19, 2011
• have been a bargaining unit, part-time faculty during 2011 Spring Term;
• currently not be eligible for the PCC part-time faculty group health insurance plans
• have taught at PCC in at least 3 out of the last 4 (Summer 2010 through Spring 2011)
terms, and had a workload of 0.4 FTE (usually two classes) or more in at least one of
those terms, and
• either spend at least $50 per month on your health insurance (the fund is not
available to provide reimbursement for out-of-pocket health expenses, e.g.,
co-payments) through a policy that you purchase independently – i.e., one that
was not made available to you by another employer/union, a spouse's
employer/union, or the government (e.g., Medicare).
• or qualify under the stricter rules that apply to those who have coverage through one
of these other sources (e.g., a spouse's employer) – see question 5 for more details.
Since the fund was primarily intended to benefit those faculty who do not have access to
health insurance through another source, the joint Management/Federation committee that
oversees the fund decided that the fund should generally not provide reimbursement to faculty
who have health insurance that is supported through PCC or another employer or other entity. Note that
the amount that each faculty will receive from the fund will depend on the number of
eligible faculty members applying to the fund. The amount to be distributed for Fall Term is
approximately $8,700. This amount will be split equally among all faculty eligible for reimbursement.
The reimbursement will not be sufficient to completely reimburse the faculty member for the cost
of their health insurance premium.
1. I was a bargaining unit part-time faculty at PCC during 2011 Spring Term who has been
covered by health insurance during that term:
•• Yes
•• No
2. I believe that I have taught at PCC in least three out of the last four terms, and have had a
workload of 0.4 FTE or more in at least one of those terms.
•• Yes
•• No
•• Uncertain
3. During Spring Term, I had health insurance coverage through:
•• a health insurance policy which I purchased independently (including a COBRA)
•• a group policy offered by another one of my other employers/my union
(Go to Question 5 if you checked this answer)
•• a group policy offered by my spouse's employer/union
(Go to Question 5 if you checked this answer)
•• a group policy offered by the government (e.g., Medicare)
(Go to Question 5 if you checked this answer)
•• other (please explain):
4. I certify, as shown in the enclosed proof of payment (e.g., an invoice marked as paid with a
canceled check, or a policy with a copy of an automatic checking account withdrawal) that:
• I paid at least $50 per month for this policy,
• The policy covers myself, myself and my spouse/partner, or myself and my family, and
• The policy was not offered by my employer, my spouse's employer or the government.
Signature: __________________________________________
Name: __________________________ College ID Number _________________
Address: _______________________________________ Apt. No.: ________________
City: _________________________________ State ______ Zip Code: _________________
Phone: __________________ PCC Campus Address _______________________
STOP. If you completed question 4, you do not need to complete question 5.
For those who obtain health insurance through another employer/union, a spouse's
employer/union, or the government:
5. I certify, as shown in the enclosed proof of payment (e.g., a payroll statement showing a
health insurance co-payment) that:
•• This health insurance covers myself, or myself and one other person (e.g., my
spouse), and I paid at least $150 per month for this policy.
•• This health insurance covers myself and at least two other persons (e.g., my spouse
and dependents), and I paid at least $300 per month for this policy.
Signature: ___________________________________________
Name: _______________________________ College ID Number__________________
Address: ___________________________________ Apt. No: _____________________
City: ______________________ State ________ Zip Code: ___________________
Phone: _____________________ PCC Campus Address ____________________________
PDF vesion here>>
Word vesion here>> |
