Page 6 - 2021-2022 New Hire Benefits

RENBROOK SCHOOL

July 1, 2021 Medical Plan Election Form

please check the appropriate plan choices, sign and date this form
Annual Employee Monthly Employee
Premium Cost Premium Cost
CT Independent Schools Health Plan Options:
ConnectiCare HMO
Choice HMO-OA-CNT-30-45-300-500D-01 HMO Open Access
Employee Only $4,693.32 $391.11 
Employee + Spouse $10,090.68 $840.89 
Employee + Child(ren) $9,152.04 $762.67 
Employee + Family $13,610.64 $1,134.22 

ConnectiCare POS
FlexPOS-CNT-30-45-300-500D-01 Open Access
Employee Only $8,812.68 $734.39 
Employee + Spouse $18,947.28 $1,578.94 
Employee + Child(ren) $17,184.84 $1,432.07 
Employee + Family $25,556.76 $2,129.73 

ConnectiCare HMO HDHP/HSA ($2K/$4K Deductible)
Choice HMO-OA-CNT-HSA-2000I/4000F-30-45-04
Employee Only $2,675.88 $222.99 
Employee + Spouse $5,753.16 $479.43 
Employee + Child(ren) $5,218.08 $434.84 
Employee + Family $7,760.04 $646.67 
ConnectiCare "Flex" POS HDHP/HSA
FlexPOS-CNT-HSA-2000I/4000F-30-45-08 Open Access
Employee Only $3,120.48 $260.04 
Employee + Spouse $6,709.08 $559.09 
Employee + Child(ren) $6,084.96 $507.08 
Employee + Family $9,049.44 $754.12 

ConnectiCare HMO HDHP/HSA ($3K/$6K Deductible)
Choice HMO-OA-CNT-HSA-3000I/6000F-30-45-05
Employee Only $1,121.64 $93.47 
Employee + Spouse $2,411.52 $200.96 
Employee + Child(ren) $2,187.36 $182.28 
Employee + Family $3,252.72 $271.06 

 I agree to have my gross salary reduced in accordance with Section 125 of the Internal Revenue Code.
These monies will be used to cover my contribution toward the benefits I have indicated above.

 I am declining all medical plan options offered above at this time.

I understand I am bound by the terms of this agreement until my employment terminates, a qualifying change occurs, my
benefits change at the beginning of a new plan year or my employer terminates, suspends, or modifies the plan.

Name ______________________________________

Signature ___________________________________ Date ________________

** Please submit original copy of this Election Form and retain a copy for your records **