Page 62 - 2021-2022 New Hire Benefits

RENBROOK SCHOOL

July 1, 2021 Voluntary Vision Plan Election Form

please check the appropriate plan choice, sign and date this form

Annual Employee Monthly Employee
Premium Cost Premium Cost
CT Independent Schools Voluntary Vision Plan Options:

EyeMed Vision Care
Employee Only $81.48 $6.79 
Employee + 1 $162.96 $13.58 
Employee + Family $262.08 $21.84 

 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 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 **