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Don Stroh Administration Center - 5606 So. 147 Street, Omaha, NE 68137 - 402-715-8200 - (Fax) 402-715-8409
Congratulations!
We are excited to have you become part of the Millard Public Schools!
We appreciate your help in expediting the hiring process by completing the new hire paperwork prior to
your scheduled appointment at the Don Stroh Administration Center.
Please bring ALL forms and documents with you to your scheduled appointment at the Don Stroh
Administration Center. A check list has been provided below to help you with this process. We will
review the forms and answer any questions at that time but please call 402-715-8200 if you have
Thank you!
questions prior to your appointment.
√ Form check list:
Form
Demographic Form
I-9 Form
Hippa Privacy Notice
OneSource Background Check Forms
W-4 Form
Direct Deposit Enrollment / Change Form
Acknowledge of MPS Board Policies & Rules
Health, Dental, LTD Enrollment Form
HSA Savings Account Application
Discovery Benefits (FSA) Spending Account
Life Insurance Enrollment Form
Nebraska Retirement Enrollment Form
403(b) Plan Notice
MPS Substitute Teacher Preference Form
Required For:
All Employee Types
All Employee Types
All Employee Types
All Employee Types
All Employee Types
All Employee Types
All Employee Types
All Employee Types
All Employee Types
All Employee Types
All Employee Types
All Employee Types
All Employee Types
Substitute Teacher
Exception
Required For:
*Please note
Substitutes
Substitutes
Substitutes
Substitutes
Substitutes
Substitutes
Substitutes
√ ‘Must Have’ Items to bring with you:
Document / Item
Voided Check for Direct Deposit
All Employee Types
Driver’s License
All Employee Types
Social Security Card
All Employee Types
Birth Certificate
All Employee Types
Certificated Staff including
Nurses
*Excluding Substitutes
Certificated Staff
All Employee Types
*Excluding Substitutes
Official Transcripts
*Teaching Certificate
Social Security Numbers for
Dependents/Beneficiaries
*Paraprofessionals may
need a copy of their
official transcripts
Includes Nursing Staff
BENEFIT ELIGIBILITY LIST 2014-15: FOOD SERVICE
10 MONTH 19 PAYS
19 Pays for
Non-Wellness
Participant
19 Pays for
Non-Wellness
Participant
TRADITIONAL PREFERED PROVIDER OPTION #1
SINGLE PPO HEALTH
EMPLOYEE + SPOUSE PPO HEALTH
EMPLOYEE + CHILDREN PPO HEALTH
EMPLOYEE + FAMILY PPO HEALTH
DISTRICT PAYS:
$170.28
$345.65
$304.50
$464.12
EMPLOYEE PAYS:
$145.12
$316.70
$279.00
$425.24
DISTRICT PAYS:
$189.23
$385.46
$339.57
$517.58
EMPLOYEE PAYS:
$126.16
$276.88
$243.92
$371.78
HIGH DEDUCTIBLE HEALH PLAN OPTION #2
SINGLE HDHP HEALTH
EMPLOYEE + SPOUSE HDHP HEALTH
EMPLOYEE + CHILDREN HDHP HEALTH
EMPLOYEE + FAMILY HDHP HEALTH
DISTRICT PAYS:
$125.94
$264.46
$232.98
$355.10
EMPLOYEE PAYS:
$110.62
$232.30
$204.64
$311.91
DISTRICT PAYS:
$141.93
$298.05
$262.57
$400.21
EMPLOYEE PAYS:
$94.62
$198.70
$175.05
$266.81
HEALTH INSURANCE (Employee may elect option #1 or
option #2)*
19 Pays for
19 Pays for
Wellness Participant Wellness Participant
ANNUAL EMPLOYER CONTRIBUTION TO HEALTH SAVINGS ACCOUNT ON HIGH DEDUCTIBLE PLAN OPTION #2 ONLY
Annual District
Annual District
Contribution
Contribution
SINGLE HDHP HEALTH
$1,550.00
$1,550.00
EMPLOYEE + SPOUSE HDHP HEALTH
$3,100.00
$3,100.00
EMPLOYEE + CHILDREN HDHP HEALTH
$3,100.00
$3,100.00
EMPLOYEE + FAMILY HDHP HEALTH
$3,100.00
$3,100.00
District Pays
19 Pays Rate
Employee Pays
19 Pays Rate
$8.67
$19.11
$16.78
$25.68
$5.78
$12.74
$11.19
$17.12
District Pays
19 Pays Rate
Employee Pays
19 Pays Rate
$50,000 TERM LIFE
$2.21
$0.00
Supplemental Life per $50,000 in coverage (any request for an increase requires Evidence of Insurability
form)
$0.00
$6.47
Spouse Supplemental Life per $25,000 in coverage (any request for an increase requires Evidence of
Insurability form)
$0.00
$2.84
Dependent Child Life $10,000 Coverage (any request for an increase requires Evidence of Insurability
form)
$0.00
$2.05
District Pays
Employee Pays
$0.00
$0.00
$0.00
$0.00
Employee Election
Employee Election
Employee Election
Employee Election
0.9878%
7.6500%
0.9780%
7.6500%
DENTAL INSURANCE*
SINGLE DENTAL
EMPLOYEE + SPOUSE DENTAL
EMPLOYEE + CHILDREN DENTAL
EMPLOYEE + FAMILY DENTAL
LIFE INSURANCE
OTHER BENEFITS
Employee Contributions - Section 125 Medical Plan for persons electing PPO Health Plan - **
electing High Deductible Health Plan - **
Employee Contributions - Section 125 Child/Elder Care Plan - **
403(b) or 457 Tax Deferred Savings Retirement Account - **
Nebraska Public Employees Retirement System (required) Social Security / Medicare (required)
* - If you and your spouse both work for the District, contact Human Resources at 402-715-8582 for possible alternate rates.
** - Employee contributions are limited by IRS Rules.
(2015 Limits = $2,500 per year for Section 125 Medical and $5,000 per year for Section 125 Child/Elder Care)
(2015 Limits for Health Savings Account = $1,800 per year for Single or $3,550 for three family tiers of coverage after District contributions)
*** - Questions about the Nebraska Public Employees Retirement System may be addressed by calling 1-800-245-5712
FAQ for New Employees
Millard Public School Benefits
Benefit Start Date for new employees is
the first day of the month following your hire date and will be effective through December 31.
*New selections can be made during Open Enrollment effective January 1.
Millard Public Schools Wellness Program
Healthy Tomorrows Wellness Program Information may be found on the MPS website (http://www.mpsomaha.org/)
→ Human Resources → Wellness → Program Details. Newly hired employees of Millard Public Schools are not
eligible for the wellness incentive.
 To receive the Wellness Premium Incentive for the next year, complete the online questionnaire and health
screening by May 30. If requirements are met, the incentive discount will start the following September 1.
 You will be able to access the Simply Well online portal starting in June. Go to the SimplyWell website,
use ME+your employee number to login. The website allows you to complete the online health risk
questionnaire and register for your health screening. http://simplywell.com. If you have problems logging in,
please contact Simply Well Tech Support at 1-877-991-9355.
Updating benefits with Millard Public Schools
Benefit changes may be made under the following circumstances:
 During Open Enrollment every October/November employees may update benefit selections effective
January 1.
 Event Change: Change in marital status, birth/adoption, death, change of spouse’s employment,
add/delete dependent. Please request the form from the Benefits Department at [email protected].
The form must be returned within 30 days of the event change.
For benefit information, please visit the MPS Website: http://www.mpsomaha.org/
MPS Website - Human Resources - HR Documents - Compensation and Benefits - Benefit Information
 The Employee Benefit Summaries Folder contains Benefit Cost Breakdowns. Choose the appropriate
pdf.
 The Plan Comparisons Folder contains specific information comparing the Traditional Plan and the High
Deductible Plan. It also goes into detail regarding HSAs.
 The Health Folder - Coventry Benefit Information contains detailed health coverage information, the
summary plan description, online provider directory, schedule of benefits and summary of deductibles.
Cards will be issued in September. If you need a temporary card before it arrives in the mail, contact
Coventry at 800-422-6890; Emergencies: 800-871-0240.
 The Dental Folder - Ameritas Benefit Information contains detailed dental coverage information, the
summary plan description, online provider directory, schedule of benefits and summary of deductibles.
Ameritas: 800-487-5553. Press 0 for the operator if you do not have your card.
 The Discovery Benefits Folder contains detailed information on Medical Flex Spending Accounts and
Dependent Care/Child Care accounts. Discovery Benefits 866-451-3399
NEW EMPLOYEE DEMOGRAPHIC INFORMATION FORM
Print Form
Please complete the following: Legal Name (as it appears on your Social Security Card): Last Name ------------------- First Name ----------------- Middle Initial Social Security Number _ Marital Status (circle the number)
Sex (circle the letter) c=
o
single
single with dependents
C=married
(;c:=female
male
0=
Ethnic Code (circle the number)
8
Race Code (circle the number) 0= American Indian or Alaska: Native
0 = Asian
0= Black or African American
0= Native Hawaiian or Other Pacific Islander
0= White
Citizenship (check one) = Hispanic or Latino or Spanish Origin
= Not Hispanic or Latino or Spanish Origin
flJ United States Citizen
~
Non-Citizen
Birth Date
Address
Street
State
City
ZIP
Phone Number - - - - ­
Employee's Emergency Contact
Name
Phone #
FOR HR USE ONLY
ID# ______
[ ] 1-9
[ 1PH
[]W4 ~_
[ ] CBC
HRlForrnsINew Employee Demographic Form
Revised 07/12/10
Employment Eligibility Verification
USCIS
Form 1-9
Department of Homeland Security
U.S . Citizenship and Immigration Services
OMS No. 1615-0047
Expires 03/31/2016
~START HERE. Read Instructions carefully before completing this form. The Instructions must be available during completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which
document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future
expiration date may also constitute illegal discrimination.
Section-1. Employee Information and Attestation (Employees 'must complete and sign Section
..
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)
First Name (Given Name)
Middle Iniliall I'her Names Used (if anv)
ICily or Town
Address (Street Number and Name)
Ail. Number,
Date of Birth (mmldcJlyyyy)
I E-mafl Address
U.S. Social Security Number
[state
Zip Code
Telephone Number
C .
I
1 of Form 1-9 no later
_
_
"
~"n
__
~
• _ _
..
~"- m
-.I
I am aware that federal law provides for imprisonment andlor fines for false statements or use of false documents in
connect/on with the completion of this form.
'attest, under penalty of perjury, that' am (check one of the following):
o
o
o
o An
A citizen of the United States
A noncitizen national of the United States (See instructions)
A lawful permanent resident (Alien Registration Number/USCIS
r------------.
Numbi!e;:;r)I,;.:~I;;;;;;;;;;;;;;;;=;;;;;;;;;;;;;;;-___-====lI
alien authorized to work until (expiration date, if applicable, mmlddlyyyy) ...If......____'"-___-.....l. bome
. . aliens may write "N/A" in this field.
(See instructions) For aliens authorized to work, provide your Alien Registrgtion Number/USC/S Number OR Form 1-94 Admission Number: 1. Alien Registration Number/USCIS NumberJ .
O
R
2. Form 1-94 Admission Number.
...
II _ _ ....
I
3-0 Barcode
Do Not Write in This Space
R
.M
If you obtained your admission number from CBP in connection with your arrival in the United States, include the following : I
I I
Foreign Passport Number:
Country of Issuance:
Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields . (See instructions) I
I Signature of Employee:
Date (mmiddlyyyy) :
I
Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the
employee.)
I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the
information is true and correct.
I
Signature of Preparer or Translator:
Date (mmiddlyyyy).
I
Last Name (Family Name)
Address (Street Number and Name)
r'orm 1-9 03/08113 N
First Name (Given Name)
ICilY or Town
j
State
j
Zlp Code
Page 70r9
:Section 2.. Ein'ployer, dr Authoi'lze~d Representative Review and Verification
(Employers or their authorized representative muSt complete and sign Sect/on 2 within 3 business days of the employee's firSt day of employment. You
must physically examine one document from List A OR examine a combination of one document from List B imd one document from List C as listed on
the "Lists of Acceptable Documents" on the next page of this form. For each document you review. record the following information: document title.
.
issuing authority. document number. and expiration date. if any.)
Employee Last Name, First Name and Middle InlUal from Section 1:
List A
OR
Identity and Employment Authorization
Document Title:
List B
AND
Liste
Identity
Document Title :
Employment AuthorizatIon
Document Title :
Issuing Authority:
Issuing Authority:
Issuing Authority:
Document Number:
Document Number:
Document Number:
ExpiraUon Date (if any)(mmiddlyyyy):
Expiration Dale (if any)(mmiddlyyyy):
Expiration Date (if any)(mmiddlyyyy):
~
~~
~
'.t
Document Title:
~
"
~,
Issuing AuThority:
j
Document Number:
Expirallon Date (if any)(mmiddlyyyy):
Document Title:
Issuing Authority:
Document Number:
I
3-D Barcode
Do Not Write in This Space
IB
Expiration Date (if any)(mmiddlyyyy):
IJ
Certification
I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the
above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
(See instructions for exemptions)
The employee's first day of employment (mm/ddlyyyy)
Signature of Employer or Authorized Representative
U
l Human Resources
IDate (mmiddlyyyy)
Title of Employer or Aulhorized Representative
I
Last Name (Family Name)
First Name (Given Name)
I Employer's Business or Organization Name
Millard Public Schools
~ State
Employer's Business or Organization Address (Street Number and Name) I City or Town
5606 S. 147 Street. Omaha. NE 68137
Section 3. Reverification and Rehires
IZi P Code
(To be completed and signed by employer or authorized representative.)
A. New Name (if applicable) Last Name (Family Name) First Name (Given Name)
Middle Initial
lB.Date Of Rehire (if applicable) (mmiddlyyyy) :
C. If employee's previous grant of employment authorization has expired. provide the Information for the document from list A or list C the employee
presented that establishes current employment authorization in the space provided below.
Document Title :
I Document Number:
1
Expiration Date (if any)(mmiddlyyyy):
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the Individual.
Signature of Employer or Authorized Representative:
Form 1-9 03/08il3 N
Date (mmiddlyyyy) :
Print Name of Emptoyer or Authorized Representative:
Page 8or9
LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED Employees may present one selection from Ust A or a combination of one selection from list B and one selection from List C . I
LIST A
Documents that Establish
Both Identity and
Employment Authoriz.ation
1. U$ Passport or U.S, Passport Card
2.. Permanent Resident Card or Alien
~
LIST B
,
0R
AND
II~ 1. Driver's license or 10 card issued by a
;.
Slate or olrtlying possession of the
s.
ti
United Slates provided il conta ins a
photograph or inrormation such as
name, date of birth, gender, height, eye
color, and address
,.
~r..,l
readable immigrant visa
}~
,:,34
I~ 2.
10 card issued by federal, siate or local
government agencies or entilies,
provided it contains a photograph or
information such as name, date of birth ,
gender, height, eye. color, and address
1::­
4. Employment Authorization Document
tha.t C9ntalns a photograph (Form
1-766)
Documents that Establish
Employment Authorization
Documents that Establish
Identity
~do.~
Registration Receipt Card (Form /·551)
3. Foreign passport Inat contains a
temporary 1-551 slamp or temporary
1·551 printed nolation on a machine· LIST C
I~
lo work for a specifiC employer
beciJuse of his or her status:
~ 4.
1':<..:-'
a. Foreign passport.; and
b. Form 1-94 or Form 1-94A Ihat has
the following:
(1) The same name as the passport;
and
.,"~,. 5,
M:
Voter's registration card
.-- - ­
U.S, Mililary card or draft record
(1) NOT VALlO'FOR EMPlOYMENT
(2) VAliD FORWORK ONLY WITH
INS AUTHORIZATION (3) VALID FOR WORK ONLY WrrH
DHS AUTHORIZATION
2. Certification of Birth Abroad issued
by the Department of State (Form
U,S, Coasl Guard Merchant Mariner
Card
Nallve American ttibal document
6. Na1lve American tribal document
Driver's license issued by a Canadian
government authority
6, U.S. Citizen ID Card (Form 1· 197)
';"-1
~ 7'
~1
8.
,:,'.:1 9.
'!,,"
fir
For persons under age 18 who are
unable to present a document
listed above:
I~i~~
I:" . 10.
3, Certificallon of Report 01 Birth
issued by the Department of State
(Form OS·1 350)
4. O(iglnal or certified copy of birttl
cert·;fic.ate issued by a State,
county. municipal authority. or
territory of Ihe United Siaies
bearing an official seal
6. Military dependent's 10 card
(2) An endorsement of the allen's
nonimmigrant status as long as
'. ,
Ihat period of endof'Sement has
~ ~
not yel expired and Ihe
proposed employmenl is nol in
conmct with any reslnctlons or ,",,', ,­
flmitalions identifled on the form ,
5. Passport from the Federated States of
Micronesia (FSM) or Ule Republic of
the MarshalllsJands (RMI) WiUl Form
card , unless lhe card includes ona 'of
the following restrictions:
FS·545)
3. SChool ID card with a photograph
5. For a nonimmigrant alien authorized
1. A Social Security Account Number
7. Identification Card for Use of
Resident Cillzen in the United
Stales (Form 1-179)
8. Employment authorization
..
School record or report card
I
L~~1 11, Clinic. doctor . or hospitat record
1-94 or Form 1·91\A indicating
. ~ 12. Day-care or nursery school record
nonimmigrant admiSsion under the Compact 01 Free ASSOCiation Belween the United Stales and the FSM or HMI document tssued by the
Department of Homeland Security
I~
I
I~'~
I
Illustrations of many of these documents appear tn
Refer to Section
2
I
Part 8 of the Handbook for Employers (M-274).
of the instructions, titled "Employer or Authoriz.ed Representat ive Review
and Verification," for more information about ac~ptable receipts.
Foml I·') 03[08 / 13 N
Pitgt 90fQ
Print Form
Confirmation of Receipt
You are required to sign and return this copy to the Millard Public Schools to confirm that you
have received a copy of this Notice. You will be provided with a copy for your records as well.
The Notice with your signature will be maintained as a part of your employment record.
I _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ acknowledge receipt of this HIP AA
Privacy Notice.
Dare: _______--_____
Division of Children and Fami~ Services
DHHS
N E 8 R A I K
~
~
Request for Child and/or AduHAbuse and
Neglect Central Register/ry Check(s)
,11111111
INSTRUCTIONS
I hereby authorize the following information request from the Nebraska Adult Central Registry and/or the Nebraska Child Abuse and Neglect
Central Register, which is maintained by the Division of Children and Family Services. Agencies agree to use the information to determine
whether to hire or retain the individual to provide care, custody, treatment, transportation or supervision of children or vulnerable aduits
All designated fields must be completed or the request will be returned and not processed. If this document is not typed, all information
must be clearly printed and legible.
AUTHORIZATION
I authorize the Division of Children and Family Services to conduct the folloWing type(s) of checks:
Adult Protective Services Central Registry
0 Child Protective Services Central Register
o
TYPE OF CHECK
Select only one:
o Agency Requested Check
Is this a request for an Adoption?
o Self Check
o
Yes
o
No
AGENCY INFORMATION: This section must be completed illhis is an,agency request.
IDNumber
Agency Name
One Source The Background Check Company
APPUCANT INFORMATION
Rrst, Middle, Last Name
Date of Birth
Social Security Number
Age
Current Address
City
E-Mail Address CFS will use this email as the
State
Zip Code
method of contact
other names previously used such as former married names, maiden name and nick names used during the
~ast
20 y'ears
CFS-5 Rev. 10112 (65655)
10 Number
First, Middle, Last Name
Names and birthdates of your children and children who lived with you
All previous addresses at which you have resided during the past 20 years (minimum Crty &State):
SIGNATURES & DATES
This signature authorizes the Division of Children and Family Services to conduct the background checks indicated and to release that
information to myself or the designated agency. This authorization is valid for a period of 6 months from the daie of signature. Custodial
guardian signature is required if the applicant is 18 years or younger.
Date
Applicant or Guardian Signature
SELF CHECK Notary is required for Self-Check only. Seal of Notary
Notary Public AGENCY CHECK
The undersigned Agency employee hereby certifies that he or she has verified the identify of the applicant by examining the applicanfs
identification documents.
Agency Employee Signature
Date
CFS-S Page 2
Print Form
~onesource
Th e Background Check Company
'
APPLICANT DISCLOSURE AND AUTHORIZATION FORM
[IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION]
DISCLOSURE REGARDING BACKGROUND INVESTIGATION
[Employer] ("The Company") may obtain information about you from a consumer reporting agency for employment purposes.
Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information
about your character, general reputation, personal characteristics, and/or mode of living, 'v'Alich can involve personal interviews
IMth sources such as your neighbors, friends, or associates. These reports may contain information regarding your credit history,
criminal history, social security verification, motor vehicle records ("driving records"), verification of your education or
employment history, worker's compensation injuries, or other background checks. You have the right, upon written request
made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative
consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report
obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted
by [One Source, The Background Check Company, PO Box 24148 Omaha, NE 68124, 1.800.608.3645] or another outside
organization . The scope of this notice and authorization is all-encompassing, hO'vVever, allo'Wing [Employer] to obtain from any
outside organization all manners of consumer reports and investigative consumer reports now and throughout the course of your
employment to the extent permitted by law. As a result, you should carefully consider 'v'Alether to exercise your right to request
disclosure of the nature and scope of any investigative consumer report .
ACKNaNLEDGMENT AND AUTHORIZATION
I ackno\AJledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR
RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I
hereby authorize the obtaining of "consumer reports" and/or '~nvestigative consumer reports' by the Company at any time after
receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation .
any law enforcement agency, administrator. state or federal agency. institution. school or university (public or private),
information service bureau, employer, or insurance company to furnish any and all background information requested by [One
Source, The Background Check Company, PO Box 24148 Omaha, NE 68124,1.800.608.3645], another outside
organization acting on behalf of [Employerl. and/or [Employer] itself. I agree that a facsimile ("fax"), electronic or photographic
copy of this Authorization shall be as valid as the original.
New York applicants or employees only: You have the right to inspect and receive a copy of any investigative
consumer report requested by [Employer] by contacting the consumer reporting agency identified above directly.
Minnesota and Oklahoma applicants or em ployees only: Please check this box if you would like to receive a copy of a
consumer report if one is obtained by the Company. [J
California applicants or employees only: By signing below, you also acknowledge receipt of the NOTICE REGARDING
BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would liketo
receive a copy of an investigative consumer report or con sum er credit report at no charge if one is obtained by the
Company Vvhenever you have a right to receive such a copy under California law. C
Last Name ______--_______________________
First ______________________ Middle ___________
Other Names/Alias_________________________________________________________________
Social Security* # _____________________
Date of Birth* ________________________________
Driver's License # _________________________
State of Driver's License ______________________
PresentAddress ____________________________________ Phone Number_________________
Cily/StatelZip,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
All Previous Addresses in the Last Seven Years
I
1
Signature**: __________________________________
Date: ________________
"This information will be used for background screening purposes only and '-Mil not be used as hiring criteria.
SUMMARY OF RIGHTS UNDER THE FCRA The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the files of
every consumer reporting agency (CRA). You can fmd the complete text of the FCRA, 15 U.S.C. 1681-1681u, at the Federal Trade
Commissions web site (http://www.fie.gov). The FCRA gives you specific rights, as outlined below. You may have additional rights
under the state law. You may contact a state or local consumer protection agency or a state attorney general to learn those rights.
I . You must be told if information in your file has been used against YOll Anyone who uses information from a CRA to take action
against you--such as denying an application for credit, insurance or employment must tell you and give you the name, address, and
phone number of the CRA that provided the consumer report.
2. You can find out what is in your file . At your request, a CRA must give you the information in your file and a list of everyone who
has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by
the eRA, if you request the report within 60 days ofreceiv ing notice of the action. You are also entitled to one free report every
twelve months upon request if you certify that (l) you are unemployed and plan to seek em ployment within 60 days, (2) you are on
welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars.
3. You can dispute inaccurate information with the eRA. If you tell a CRA that your file contains inaccurate information, the CRA
must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless
your dispute is frivolous. The source must review your evidence and report its findings to the CRA. (The source also must advise
national CRAs--to which it has provided the data, of any error.) The CRA must give you a written report of the investigation and a
copy of your report if the investigation results in any change. If the CRAs investigation does not resolve the dispute, you may add a
brief statement to your file . The CRA must normally include a summary of your statement in future reports. If an item is deleted or
dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change.
4. Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its
files, usually within 30 days after you dispute it. However, the CRA is not reqillred to remove accurate data from your file unless it is
outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into
your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a
written notice telling you it has reinserted the item . The notice must include the name, address and phone num ber of the information
source.
5. You can dispute inaccurate items with the source of the information. If you tell anyone-such as a creditor who reports to the CRA-­
that you dispute an item , they may not then report the information to a CRA without including a notice of your dispute. In addition,
once you*ve notified the source of the error in writing, it may not continue to report the information if it is, in fact, an error.
6. Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years
old; ten years for bankruptcies.
7. Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA,
usually to consider an application with a creditor, insurer, employer, landlord, or other business.
8. Your consent is required for reports that are provided to employers or reports that contain medical information. A CRA may not
give out information about you to your employer, or prospective employer, without your written consent A CRA may not report
medical information about you to creditors, insurers, or employers without your permission.
9. You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors and insurers may use
file information as the basis for sending you unsolicited offers of credit or insurance. Such offers must include a toll-free phone
number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the lists for two
years. If you request, complete and return the CRA form provided for this purpose, you must be taken off the lists indefinitely.
10, You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violates the FCRA, you may sue them in state or federal court. The FCRA gives several different federal agencies authority to enforce the FCRA. For questions or concerns regarding: CRAs, creditors and others not listed below, please contact: Federal Trade Commission Bureau of Consumer Protection-FCRA, Washington., DC 20580 (202) 326-3761 National banks, federal branches/agencies of foreign banks, please contact: Office of the Controller of the Currency Compliance Management, Mail Stop 6-6 Washington., DC 20219 (800) 613-6743 Federal Reserve System member banks, please contact: Federal Reserve Board Division of Consumer & Comm unity Affairs Washington., DC 20551 (202) 452-3693 Savings associations and federally chartered savings banks, please contact: Office ofThrift Supervision Consumer Programs Washington., DC 20552 (800) 842-6929
Federal credit unions, please contact:
National Credit Union Administration
775 Duke Street
Alexandria, VA 22314
(703) 518-6360
Federal Deposit In.:"lIance Corporation
Division of Compliance & Consumer Affairs
Washington., DC 20429
(800) 934-FDIC
Air, surface or rail common carriers regulated by former Civil Aeronautics Board of Interstate Commerce Commission., please
contact:
Department of Transportation
Office of Financial Management
Washington., DC 20590
(202) 366-1306
Activities subject to the Packers and Stockyards Act, 1921, please contact:
Department of Agriculture
Office of Deputy Administrator-GlPSA
Washington., DC 20250
(202) 720-7051
Form W-4 (2015)
The exceptions do not apply to supplemental wages
greater than $1,000,000.
Basic Instructions. If you are not exempt , complete
the Personal Allowances Worksheet below. The
wor1<sheets on page 2 further adjust your
withholding allowances based on itemized
deductions, certain credits, adjustments to Income,
or two-eamers/multlple jobs situations .
Complete all wor1<sheets that apply. However, you
may claim fewer (or zero) allowances . For regular
wages, w~hholdlng must be based on allowances
you claimed and may not be a flat amount or
percentage of wages .
Head of household. Generally, you can claim head
of household filing status on your tax retum only if
you are unmarried and pay more than 50% of the
costs of keeping up a home for yourself and your
dependent(s) or other qualifying Individuals. See
PUb. 501, Exemptions, Standard Deduction, and
Filing Information, for Information.
Tax eNldlts. You can take projected tax cred~s Into account
in figuring your allowable number of w~hholdlng allowances.
Credits for child or dependent care expenses and the child
tax credit may be claimed using the Personal Allowances
Wor1<sheet below. See Pub. 505 for Information on
converting your other credits into withholding allowances.
Purpose. Complete Form W-4 so that your employer
can withhold the correct federal Income tax from your
pay. Consider completing a new Form W-4 each year
and when your personal or financial situation changes.
Exemption from withholding. If you are exempt,
complete only lines 1, 2, 3, 4, and 7 and sign the form
to validate It. Your exemption for 2015 expires
February 16, 2016. See PUb. 505, Tax Withholding
and Estimated Tax.
Note. If another person can claim you as a dependent
on his or her tax retum, you cannot claim exemption
from withholding if your income exceeds $1 ,050 and
Includes more than $350 of uneamed income (for
example, interest and dividends).
Except/ons . An employee may be able to claim
exemption from withholding even if the employee is a
dependent, if the employee:
o Is age 65 or older,
ols blind, or
o Will claim adjustments to income; tax credits; or
itemized deductions, on his or her tax retum.
Nonwage Income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using Form
1040-ES. Estimated Tax for Individuals. Otherwise, you
may owe additional tax. If you have pension or annuity
Income, see PUb. 505 to find 0U1 if you should adjust
your withholding on Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
wor1<ing spouse or more than one job, figure Ihe
total number of allowances you are entitled to claim
on all Jobs using worksheets from only one Form
W-4 . Your withholding usually will be most accurate
when all allowances are claimed on the Form W-4
for the highest paying job and zero allowances are
claimed on the others. See Pub. 505 for details.
Nonresident allen. If you are a nonresident alien,
see Notice 1392, Supplemental Form W-4
Instructions for Nonresident Aliens, before
completing this form .
Check your wtthholdlng. After your Form W-4 takes
effect, use Pub. 505 to see how the amount you are
having withheld compares to your projected total tax
for 2015. See Pub. 505, especially If your eamings
exceed $130,000 (Single) or $180,000 (Married).
Future developments. Information about any Mure
developments affecting Form W-4 (such as legislation
enacted after we release it) will be posted at www.irs.gov/w4.
Personal Allowances Worksheet (Keep for your records.)
A
Enter
"1" for yourself if no one else can claim you as a dependent . A
• You are single and have only one job; or
B
Enter "1 " if:
}
B
• You are married, have only one job, and your spouse does not work; or
{
• Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less. Enter "1" for your spouse. But, you may choose to enter " -0-" if you are married and have either a working spouse or more C
than one job. (Entering " -0-" may help you avoid having too little tax withheld .) . C
o
Enter number of dependents (other than your spouse or yourself) you will claim on your tax retum .
o
E
Enter "1" if you will file as head of household on your tax return (see conditions under Head of household above)
F
Enter "1" if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit
E
F
(Note. Do not include child support payments . See Pub. 503, Child and Dependent Care Expenses, for details.)
Child Tax Credit (including additional child tax credit) . See Pub. 972 , Child Tax Credit, for more information .
G
• If your total income will be less than $65 ,000 ($100,000 if married), enter "2 " for each eligible child ; then less " 1" if you have two to four eligible children or less
"2" if you have five or more eligible children. • If your total income will be between $65,000 and $84,000 ($100,000 and $119,000 if manied), enter "1" for
each eligible child .
G
Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax retum.) ~ H
H
For accuracy,
complete all
worksheets
that apply.
(
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
and Adjustments Worksheet on page 2 .
• If you are single and have more than one job or are married and you and your spouse both work and the combined
eamings from all jobs exceed $50,000 ($20,000 If married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to
avoid having too little tax withheld .
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
---------------------------------- Separate here and give Form W-4 to your employer. Keep the top part for your records. ---------------------------------­
W-4
Employee's Withholding Allowance Certificate
OMS No. 1545-0074
Form
~ Whether you are entitled to claim a certain number of allowances or exemption from withholding Is
Department of the Treasury
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Intemal Revenue SeMce
Your social security number
Last name
1
Your first name and middle initial
~@15
12
1
Home address (number and street or rural route)
3
0
Single
o
Married
o
Married, but withhold at higher Single rate.
Note. If married, but legally separated, or spouse Is a nonresident allen, check the "Single" box.
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. ~
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
7
I claim exemption from withholding for 2015, and I certify that I meet both of the following condit ions for exemption.
Additional amount, if any, you want withheld from each paycheck
0
5
6 $
5
6
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write "Exempt" here. ..
~171
Under penaltles of pequry, I declare that I have examined thiS certificate and, to the best of my knowledge and belief, It IS true, correct, and complete.
Employee's signature (This form is not valid unless you sign it.) ~ 8
Employer's name and address (Employer: Complete lines 8 and 10 only If sending to the IRS.)
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Date~
9 Office code (optional)
Cat. No. 102200 10
Employer identification number (EIN)
Form
W-4 (2015)
Form W-4 (2015)
Page 2
Deductions and Adjustments Worksheet
Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
1
Enter an estimate of your 2015 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state
and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was bom before January 2, 1951) of your
income, and miscellaneous deductions. For 2015, you may have to reduce your ~emized deductions if your income is over $309,900
and you are married filing jointly or are a qualifying widow(er): $284,050 if you are head of household: $258,250 if you are single and not
head of household or a qualifying widow(er): or $154,950 if you are married filing separately. See PUb. 505 for details
$12,600 if married filing jointly or qualifying widow(er)
Enter:
$9,250 if head of household
2
$6,300 if single or married filing separately
Subtract line 2 from line 1. If zero or less, enter "-0-"
3
4
Enter an estimate of your 2015 adjustments to income and any additional standard deduction (see Pub. 505)
Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to
5
Withholding Allowances for 2015 Form W-4 worksheet in PUb. 505.) .
{
6
7
8
9
10
}
Enter an estimate of your 2015 nonwage income (such as dividends or interest)
Subtract line 6 from line 5. If zero or less, enter "-0-"
Divide the amount on line 7 by $4,000 and enter the result here. Drop any fraction
Enter the number from the Personal Allowances Worksheet, line H, page 1
Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,
also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1
1
$
2
$
3
$
$
4
5
6
7
$
$
$
8
9
10
Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1 .)
Note. Use this worksheet only if the instructions under line H on page 1 direct you here.
1
Enter the number from line H, page 1 (or from line 10 above if you used the Deductioos and Adjustments Worksheet)
1
2
Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more
than "3"
2
3
If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
"-0-") and on Form W-4, line 5, page 1. Do not use the rest of this worksheet .
3
Note. If line 1 is less than line 2, enter "-0-" on Form W-4, line 5, page 1. Complete lines 4 through 9 below to
figure the additional withholding amount necessary to avoid a year-end tax bill.
4
5
6
7
8
9
Enter the number from line 2 of this worksheet
4
Enter the number from line 1 of this worksheet
5
Subtract line 5 from line 4 .
Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here
Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed
6
-
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Married Filing Jointly
All Others
Married Filing Jointly
$0 - $6.000
6,001
13,000
24,000
13,001
26,000
24,001
26,001
34,000
34,001 - 44,000
44,001
50,000
50,001 - 65,000
65,001
75,000
80 ,000
75,001
80,001
100,000
100,001
115.000
130.000
115.001
140.000
130.001
140.001
150.000
150,001 and over
9
$
Table 2
Table 1
Enter on
line 2 above
$
$
7
Divide line 8 by the number of pay periods remaining in 2015. For example, divide by 25 if you are paid every two
weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2015. Enter
the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck
If wages from LOWEST
paying job are-
8
If wages from LOWEST
paying job are-
SO - $8,000
8,001 - 17,000
17,001 - 26,000
26,001
34,000
44,000
34,001
75,000
44,001
75,001
85,000
85,001
110,000
125,000
110,001
125,001
140,000
140,001 and over
-
Enter on
line 2 above
0
1
2
3
4
5
6
7
8
If wages from HIGHEST
paying job are$0 - $75,000
75,001 - 135,000
135,001 - 205,000
205,001 - 360,000
360,001 - 405,000
405,001 and over
Enter on
line 7 above
$600
1,000
1,120
1,320
1,400
1,580
All Others
If wages from HIGHEST
paying job are-
$0 - $38,000
38,001 - 83,000
83,001 • 180,000
180,001 - 395,000
395,001 and over
Enter on
line 7 above
$600
1.000
1,120
1,320
1,580
9
10
Privacy Act and PaperworX Reduction Act Notice. We ask for the information on this
form to carry out the Internal Revenue laws of the United States. Internal Revenue Code
sections 3402(1)(2) and 6109 and their regulations require you to provide this information; your
emplover uses it 10 determine your federal income tax withholding. Failure to provide a
proper1y completed form will resutt In your being treated as asingle person who claims no
withholding allowances: providing fraudulent Information may subject you to penalties. Routine
uses of this Information indude giving ~ to the Department of Justice for civil and criminal
litigation; to cities, states. the District of Columbia. and U.S. commonwealths and possessions
for use In administering their tax laws; and to the Department of Health and Human Services
for use in the National Directory of New Hires. We may also disclose this infonnation to other
countries under a tax treaty. to federal and state agencies to enforce federal nontax criminal
laws, or to federal law enforcement and intelligence agencies to combat terrorism.
You are not required to provide Ihe information requested on aform that IS sublectto the
PaperworK Reduction Act unless the form displays avalid OMB control number. Books or
records relating to aform or its instructions must be retained as long as their contents may
become material in the administration of any Internal Revenue law. Generally. tax returns and
return information are confidential. as required by Code section 6103.
The average time and expenses required to complete and file this form will vary depending
on individual circumstances. For estimated averages. see the instructions for your Income tax
return.
If you have suggestions for making this form simpler. we would be happy to hear from you.
See the instructions for your income tax return.
m
Print Form
MIllARD PUBlIC SCHOOlS
DIRECT DEPOSIT - ENROLLMENT/CHANGE FORM
I,
request Millard Public Schools directly deposit my paycheck
into the referenced account(s}. I further authorize Millard Public Schools to request my bank to debit my account
for any direct deposit made in error.
Signed: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Dated:
Employee Number: _ _ _ _ _ _ _ _ _ _ _ __
SSN: ___________________
Pleose attached a voided check or letter from your bank
containing your routing information
Please Note: Direct Deposit change requests must be received by the Business Office at least 7 days prior to
the next paydate. If you close your account(s), please let the Payroll Department know immediately. We are
not responsible for payments made to closed accounts.
PRIMARY BANK ACCOUNT: Bank Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Account Type: _ _ _ _ _ __ =
=
C Checking, S Savings
Bank Routing Number: _ _ _ _ _ _ _ _ _ _ _ __
Bank Account Number: _ _ _ _ _ _ _ _ _ _ _ __
SECONDARY BANK ACCOUNT (optional):
Bank Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _~_ _ Account Type: _ _ _ _ _ __
=
=
C Checking, S Savings
Bank Routing Number: _ _ _ _ _ _ _ _ _ _ _ __
Bank Account Number: _ _ _ _ _ _ _ _ _ _ _ _ _ $ Amount to be Deposited: _ _ _ __
Bank Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Account Type: _ _ _ _ _ __
=
=
C Checking, S Savings
Bank Routing Number: _ _ _ _ _ _ _ _ _ _ _ __ Bank Account Number: _ _ _ _ _ _ _ _ _ _ _ _ _ $ Amount to be Deposited: _ _ _ __ Bank Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Account Type: _ _ _ _ _ __
=
=
C Checking, S Savings
Bank Routing Number: _ _ _ _ _ _ _ _ _ _ _ __
Bank Account Number: _ _ _ _ _ _ _ _ _ _ _ _ _ $ Amount to be Deposited: _ _ _ __
Revbed 6/2013
I hereby acknowledge that I have been informed of the Millard Public Schools Board Policies and Rules found at: http://mps.schoolfusion.us/modules/cms/pages.phtml?pageid=97377&sessionid=f3ecb655058a1cc61c584da728c7d5bc&sessionid
=f3ecb655058a1cc61c584da728c7d5bc I further acknowledge that it is my responsibility to know and abide by all Policies and Rules of the Millard Public Schools Board of Education including, but not limited to the Polices and Rules on: 1235.1 1315 1315.1 3131.2 4001 4001.1 4001.2 4105 4105.1 4140 4140.1 4140.2 4155 4155.1 4163 4163.1 4163.2 4172 4172.1 4173 4173.1 4173.2 4173.3 4315 4315.1 4315.2 4325 4325.1 6110 6110.1 6200 6200.1 6203 6240 6240.1 6315 6315.1 Conduct on District Policy
Gifts to School Personnel
Gifts to School Personnel
Employee Indemnification/Hold Harmless
Non Discrimination and Sexual Harassment Policy
Sexual Harassment
Discrimination and Sexual Harassment Complaint and Grievance Procedures
Mentor and New Staff Induction Program
Mentor and New Staff Induction Program
Responsibilities and Duties
Responsibilities and Duties – Certificated
Responsibilities and Duties – Non‐Certificated
Code of Ethics
Code of Ethics
Remedial Action
Remedial Action: Certificated
Remedial Action: Non‐Certificated
Smoking and Use of Tobacco
Smoking and Use of Tobacco
Drug‐Free Workplace
Drug‐Free Workplace
Drug‐Free Workplace: Alcohol
Drug‐Free Workplace: Drugs
Non‐School Employment
Non‐School Employment
Tutoring
Grievances
Grievance Procedure
Written Curriculum: Content Standards
Written Curriculum: Content Standards
Taught Curriculum: Instructional Delivery
Taught Curriculum: Instructional Delivery
Taught Curriculum: Lesson (Instructional) Plans
Taught Curriculum: Controversial Issues
Taught Curriculum: Controversial Issues
Millard Education Program: Use of Assessment Data
Millard Education Program: Use of Assessment Data
I understand and acknowledge the Millard Public Schools Board Policies and Rules are amended form time to time and recognize that it is my responsibility to remain aware of all changes to Board Policies and Rule as may be posted on the Millard Public Schools Board of Education website. Print Name __________________________________________ Signature __________________________________________ Date __________________________________________ NOTICE OF NONDISCRIMINATION 




The District does not discriminate on the basis of race, color, religion, national origin, gender, marital status, disability, or age in admission or access to or treatment of employment, or in its programs and activities. The District shall provide an employment, teaching and learning environment free from sexual harassment. Personnel violating this Policy shall be subject to disciplinary action. The following person has been designated to handle inquiries regarding the non‐discrimination policies: Superintendent of Schools, 5606 S. 147th Street, Omaha, NE 68137 (402)715‐8200. The Superintendent may delegate this responsibility as needed. Complaints and grievances by school personnel or job applicants regarding discrimination or sexual harassment shall follow the procedures of District Rule 4001.2. Event(s) or Reason(s)
for Changing Contract
Please return this form to HR at DSAC within 30
days of the qualifying event change
Benefit Enrollment Form
 New Hire
 Add/Delete Dependent




Marriage
Death
 Change of Spouse’s Employment
 Other, Please Specify Below
Birth/Adoption
Divorce
__________________________
Date of
Event:_____________________
A. EMPLOYEE INFORMATION
First Name
M.I.
Last Name
Social Security
Sex
Birthdate
Number
Street Address
Apt. No.
Home Phone
Work phone
Hire Date
Effective Date
Occupational / Job Title
City
State
ZIP Code
County
Marital Status


# Hours Scheduled
Part-time
Each Week
Full-time
B. BENEFIT SELECTION
MEDICAL BENEFITS
(Administered by Coventry Health Care)
Choose Option:

Employee Only

Employee + Spouse

Employee + Child(ren)

Employee + Spouse + Children
(Full Family)

(Insured & administered by
Ameritas®)
TRADITIONAL PPO
Choose Tier:

DENTAL BENEFITS
OR


Employee Only
HIGH DEDUCTION HEALTH PLAN
(please check all that apply)

Employee + Spouse


Employee + Child(ren)


Yes, I am eligible for the HSA
Employer Contribution
Employee Contribution (HSA
Enrollment Form must be completed)

Decline Medical Benefits



List all family members to be covered. Write name as it should appear on I.D. card.
Indicate dependent address (if different) in the space provided below.
Attach additional enrollment form if enrolling more than 5 members.
First Name
M.I.
Last Name
Social Security Number
Relationship
01
Spouse’s Employer:
02
03
04
05
06
Employee + Spouse +
Children (Full Family)
SPOUSE
Sex
Decline Dental Benefits
Birthdate
D. OTHER HEALTH INSURANCE INFORMATION
ON THE DAY YOUR COVERAGE BEGINS, WILL ANY FAMILY MEMBER
(INCLUDING THOSE NOT LISTED IN SECTION C) BE COVERED BY OTHER
HEALTH OR DENTAL INSURANCE OR MEDICARE?
Coverage Type
(THIS SECTION MUST BE COMPLETED)

Yes

Insurance Company Name, Address and Phone Number

Medical Insurance

Dental Insurance
 Medicare
Policy Coverage Date
Name of Policyholder
______ To ______
Policyholder’s Employer:
Name
Names of family members covered by Medicare
E. SIGNATURE
Policyholder’s Birthdate
Address
Medicare Claim Number
No
IF YES, FILL OUT THIS
SECTION:
Policy Number
Family Members Covered
Phone Number
Part A Effective Date
Part B
Effective Date
Is Medicare eligibility due to:
 Kidney Failure 
Disability
(THIS FORM MUST BE SIGNED)
The information provided on this application is accurate and complete. I declare that I am actively at work on the date of this enrollment
form. I understand and agree that any omission or incorrect statements knowingly made by us on this application may invalidate my
and / or my dependents coverage. If contributions are required, I authorize my employer to deduct premiums from my salary. No
insurance is in force until this application is accepted by the home office.
NOTICE OF SPECIAL ENROLLMENT RIGHTS
I understand that if I am declining enrollment for myself or my dependents (including my spouse) because of other health coverage, I
may in the future be able to enroll myself or my dependents in this plan, provided that I request enrollment within 30 days after such
coverage ends. If the reason I lose other coverage is due to fraud or failure to pay premiums, I understand that I will not be entitled to
Special Enrollment. In addition, if I have a new dependent as a result of marriage, birth, adoption or placement for adoption, I may be
able to enroll myself and my dependents, provided that I request enrollment within 30 days after marriage, birth, adoption or placement
for adoption.
AUTHORIZATION TO OBTAIN OR RELEASE MEDICAL INFORMATION
On behalf of myself and anyone enrolled on or added to this application (“Us”), I authorize any health care professional or entity to give
Coventry Health Care, or any of their designees, any and all records or information pertaining to medical history or services rendered to
Us for any administrative purpose, including evaluation of an application or a claim, and for any analytical or research purposes. I also
authorize on behalf of Us the use of a Social Security Number for purpose of identification. The information provided on this application
is accurate and complete. I understand and agree that any omissions or incorrect statements knowingly made by Us on this application
may invalidate my and /or my dependents’ coverage.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a
statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
____________________________________
___________________________
Employee’s Signature
Date
F. FOR EMPLOYER USE ONLY
Millard Public Schools
Notes:
Approved By (Signature)
Date
Physical
Physical Street Address
FORM_HSA_Application_Eligibility_SP_EV1_100114
Flexible Spending Account (FSA) Data Collection
Worksheet
Please complete and submit this worksheet to your employer. This is an internal document used by your employer for data collection
purposes. Worksheets submitted to Discovery Benefits will not be processed.
*= Required Fields
Step 1: Participant Information
*Employer Name (Do not abbreviate)
*Employee Identifier Number
*Participant Name (First, MI, Last)
*Social Security Number
*Participant Mailing Address
Email Address (If provided, all notifications will be sent via email)
*City
*State
-
-
-
*Zip
-
Day Telephone
Gender (Please circle one): Please
Male / Female
select:
*Birth Date (mm/dd/yyyy)
*Hire Date (mm/dd/yyyy)
Marital Status (Please circle one):Please
Married / select:
Single
Step 2: Employee Premiums
If you have a payroll deduction for insurance premiums, eligible premiums will be deducted before taxes are calculated. You will automatically be enrolled in this portion of your
Section 125 Plan. However, if you wish, you may opt out of the Employee Premium Conversion part of the Plan by contacting your HR Department and filling out the waiver
form. *Please Note: Insurance premiums are not eligible for reimbursement with your Medical or Limited Medical Spending Account.
Step 3: Enrollment and Election Information
*Plan Type (If enrolled in an HSA, you are not eligible to enroll in the
Dependent Care Account
Medical FSA
Medical FSA. However, you are eligible for both the Limited Medical FSA and
Dependent Care FSA if offered through your employer.)
Limit set by employer up to IRS
maximum
Limit set by employer
*Annual Election (if employer funded, note ‘ER’ next to amount)
$
$
*Number of Pay Periods (if enrolling mid-year, please enter the number
÷
÷
=
=
of remaining pay periods within the plan year)
*Per Pay Period Amount (to be deducted each pay period)
*Date of First Payroll (mm/dd/yyyy)
*Participant Effective Date (mm/dd/yyyy)
*Pay Frequency (please circle one)
Monthly / Semi-Monthly / Bi-Weekly 24 / Bi-Weekly 26 / Weekly / Other
Step 4: Authorization
I authorize my employer to reduce my pay on a per pay period basis as indicated above. I understand my reduction is for one flex plan year and that I cannot change or revoke
my election unless I experience a qualifying event in accordance with Internal Revenue Code Section 125 and submit my request within a reasonable amount of time as
deemed by the IRS and my employer. I am aware of the plan's forfeiture provision and that my Social Security and federal unemployment benefits may be reduced because of
my reduced salary for tax purposes. Further, I authorize the release of any information necessary to substantiate claims submitted against my Flexible Spending Account.
*Participant Signature
*Date
Step 5: Refusal (**NOTE: only complete this step if you are NOT electing to enroll in a Flexible Spending Account)
I understand that if I choose not to participate in a Flexible Spending Account (FSA) , I cannot enter the program until the next plan year unless I experience a status change in
accordance with Internal Revenue Code Section 125 and submit the change within 30 days of the status change.
*Participant Signature
*Date
Income Protection Benefits
Millard Public Schools
Policy Number 398481
Benefits Enrollment Form for All Other Employees
Information About You
Name:
Social Security Number / Employee ID Number:
Date of Birth:
Date of Hire:
Instructions
Please enter all required information clearly so that there will be no question as to your meaning.
 Step 1: Please enter or check your coverage elections and details. You may only elect – and will be covered for –
levels of coverage included in your employer’s contract.
 Step 2: Please sign, date and return this form to Human Resources
Employee Basic Life Insurance
Millard Public Schools provides, at no cost to you, Basic Life Insurance in an amount equal to $50,000.
Supplemental Life and AD&D Insurance
You can purchase Supplemental Life and AD&D Insurance in increments of $25,000. The maximum amount you can purchase cannot be
more than $300,000. If you elect an amount that exceeds the guaranteed issue amount of $150,000, you will need to provide evidence of
insurability that is satisfactory to The Hartford before the excess can become effective.
Employee Supplemental Life and AD&D Insurance
$25,000 ($5.13/month)
$100,000 ($20.50/month)
$175,000 ($35.88/month)
$250,000 ($51.25/month
$50,000 ($10.25/month)
$125,000 ($25.63/month)
$200,000 ($41.00/month)
$275,000 ($56.38/month)
$150,000 ($30.75/month)
$225,000 ($46.13/month)
$300,000 ($61.50/month)
$75,000 ($15.38/month)
I decline to purchase Supplemental Life and AD&D Insurance coverage
Supplemental Dependent Life and AD&D Insurance
If you purchase Supplemental Life and AD&D for yourself, you can purchase Supplemental Life and AD&D Insurance for your Spouse and
Supplemental Life and AD&D for your Dependent Child(en). You can purchase coverage for your Spouse in increments of $12,500. The
maximum amount you can purchase cannot be more than the lesser of $150,000 or 50% of your Supplemental Life and AD&D Insurance. If
you elect an amount that exceeds the guaranteed issue amount of $25,000, your Spouse will need to provide evidence of insurability that is
satisfactory to The Hartford before the excess can become effective. You can purchase coverage for your Dependent Child(ren) between the
ages of Birth and 23 years in the amount(s) of $10,000.
Spouse Supplemental Life and AD&D Insurance
$12,500 ($2.25/month)
$50,000 ($9.00/month)
$87,500 ($15.75/month)
$125,000 ($22.50/month)
$25,000 ($4.50/month)
$62,500 ($11.25/month)
$100,000 ($18.00/month)
$137,500 ($24.75/month)
$37,500 ($6.75/month)
$75,000 ($13.50/month)
$112,500 ($20.25/month)
$150,000 ($27.00/month)
I decline to purchase Supplemental Life and AD&D Insurance coverage for my Spouse
Child(ren) Supplemental Life and AD&D Insurance
I elect to purchase Supplemental Dependent Life and AD&D
I decline to purchase Supplemental Dependent Life and
Insurance coverage for my Child(ren) at a cost of $3.25 per month AD&D Insurance coverage for my Child(ren).
Underwritten by Hartford Life And Accident Insurance Company. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including
issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by
Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in
force or discontinued.
Name: _______________________________________________________________________________
Spouse First Name
Child First Name
Spouse Last Name
Gender
Child Last Name
Date of Birth
Date of Birth
Date of Marriage
Gender
Beneficiary Designation
You must select your beneficiary – the person (or more than one person) or legal entity (or more than one entity) who receives a benefit
payment if you die while covered by the plans. This beneficiary designation will be for ALL group life or accidental death insurance
coverage issued by The Hartford for you, unless specifically named otherwise. Please make sure that you also name a contingent
beneficiary – who would receive your benefit if your primary beneficiary dies first.
Please make sure your beneficiary designation is clear so that there will be no question as to your meaning. If you name more than one
primary or contingent beneficiary, show the percentage of your benefit to be paid to each beneficiary. Please provide all of the information
requested below. If your beneficiary is not related either by blood or by marriage, insert the words, “Not Related” as their stated relationship.
If you need assistance, contact your benefits administrator or your own legal advisor.
Full Name
Address
Social
Security #
Relationship
Date of
Birth
Percentage
Primary
Beneficiary
Contingent
Beneficiary
The beneficiary for insurance on the lives of your spouse and children will automatically be you, if surviving. Otherwise, the beneficiary will
be the estate of the spouse and children, subject to policy provisions. A beneficiary for employee Life Insurance may be changed upon
written request.
Confirmation
I acknowledge that I have been given the opportunity to enroll in the Life and Accident insurance coverage described in the Benefit Highlight
Sheets and offered through Millard Public Schools.
I understand and agree that if I decline coverage now, but later decide to enroll, I will be required to provide evidence of insurability that is
satisfactory to The Hartford and be approved for such coverage before it becomes effective. I understand my request for coverage may be
denied by The Hartford.
I understand and agree that insurance will go into effect and remain in effect only in accordance with the provisions, terms and conditions of
the insurance policy. I understand and agree that only the insurance policy issued to the policyholder (your employer) can fully describe the
provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the enrollment
form and the insurance policy, I agree to be bound by the insurance policy.
If I have life insurance coverage with The Hartford, I understand and agree that my life insurance benefit is reduced at a specified age stated
in the policy
I authorize my employer to make the appropriate payroll deductions from my earnings.
I understand that no insurance will be valid or in force if I am not eligible in accordance with the terms of the group policy as issued to my
employer. I acknowledge and agree that if group participation requirements are not met, this policy will not be implemented and the
coverage I have elected will not be in force.
Signed
Date
Underwritten by Hartford Life and Accident Insurance Company. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including
issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by
Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in
force or discontinued.
Name
Last
First
Middle
Maiden
Date of Birth
Social Security Number
-
-
Plan Type
-
(check all that apply)
School
State
County
Judges
Patrol
DCP
Retirement Number
Address
City
Home Phone
-
Work Phone
State
Zip
Employer
Beneficiary Designation Form
READ CAREFULLY BEFORE COMPLETING: Use this form to designate or change your beneficiaries for the Retirement Plan indicated
above. Benefits will be paid to your survivors exactly as you provide on this form. This form supersedes prior beneficiary designation
forms. If you name a trust or other legal entity as your beneficiary, include the name of both the trust and the trustee. Submit the original
document only; photocopies and faxes will not be accepted. If you wish to designate more than three beneficiaries in either the
Primary or Contingent category, you must attach a supplemental form(s) and indicate the number of additional pages here. ________
PRIMARY BENEFICIARY(IES): I designate the following person(s) to be my Primary Beneficiary(ies) for the Retirement Plan noted
above. All Primary Beneficiaries designated will share equally in the benefit unless I have included a percentage (%) amount on the line
following the date of birth below. (The shares of all Primary Beneficiaries must total 100%.) PLEASE PRINT.
_____________________________________________ __________________ M / F _______________________ ________________ ______
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
%
__________________________________________________________ ___________________________________ ________ _______________
Address
City
State
Zip
M // FF _______________________ ________________ ______
_____________________________________________ __________________ M
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
0.00
%
__________________________________________________________ ___________________________________ ________ _______________
Address
City
State
Zip
M // FF _______________________ ________________ ______
_____________________________________________ __________________ M
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
%
______________________________________________________ ___________________________________ __________ _________________
Address
City
State
Zip
CONTINGENT BENEFICIARY(IES): I designate the following person(s) to be my Contingent Beneficiary(ies) for the Retirement Plan
noted above. I understand my Contingent Beneficiary(ies) will receive a share of my benefit if all Primary Beneficiaries pre-decease me or refuse
their shares of the benefit. All Contingent Beneficiaries designated will share equally in the benefit unless I have included a percentage (%)
amount on the line following the date of birth below. (The shares of all Contingent Beneficiaries must total 100%.) PLEASE PRINT.
M // F
F _______________________ ________________ ______
_____________________________________________ __________________ M
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
%
__________________________________________________________ ___________________________________ ________ _______________
Address
City
State
Zip
M // F
F _______________________ ________________ ______
_____________________________________________ __________________ M
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
%
__________________________________________________________ ___________________________________ ________ _______________
Address
City
State
Zip
M // FF _______________________ ________________ ______
_____________________________________________ __________________ M
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
%
______________________________________________________ ___________________________________ __________ _________________
Address
City
State
Zip
SIGNATURE OF MEMBER________________________________________________________________________________ Date _____________________
I hereby certify that the above member, whose identity I have established to my own
satisfaction, freely and voluntarily signed this beneficiary designation form in my presence.
State of ______________________________
County of_____________________________
}
STAMP HERE
Subscribed and sworn before me this ______ day of _______________________, ____________.
NOTARY PUBLIC SIGNATURE _________________________________________________________ My commission expires: __________________.
NPERS1300
Rev. 09/2013
Page 1 of ______
BAR CODE
0.00
Beneficiary Designation Supplemental Form
IMPORTANT: This form is to be used as a supplement to the Beneficiary Designation Form only if you wish to
designate more than three Primary or Contingent Beneficiaries. You may use as many Supplemental forms as
needed. This form will NOT be accepted without the original, notarized Beneficiary Designation Form.
NAME ________________________________________________________________________________________________________________________________
Social Security Number ________________-_____________-________________ Retirement Number ____________________________________
PRIMARY BENEFICIARY(IES) (continued):
Fill in a percentage amount (%), for all persons designated below (the shares of all primary beneficiaries must total 100%,
including those listed on page 1). If all beneficiaries are to share equally, no percentage needs to be listed. PLEASE PRINT.
M // F
F _______________________ ________________ ______
_____________________________________________ __________________ M
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
%
____________________________________________________________ ___________________________________ _______ ______________
Address
City
State
Zip
M // F
_____________________________________________ __________________ M
F _______________________ ________________ ______
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
%
____________________________________________________________ ___________________________________ _______ ______________
Address
City
State
Zip
M // F
F _______________________ ________________ ______
_____________________________________________ __________________ M
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
0.00
%
____________________________________________________________ ___________________________________ _______ ______________
Address
City
State
Zip
M // F
F _______________________ ________________ ______
_____________________________________________ __________________ M
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
%
____________________________________________________________ ___________________________________ _______ ______________
Address
City
State
Zip
CONTINGENT BENEFICIARY(IES) (continued):
Fill in a percentage amount (%), for all persons designated below (the shares of all contingent beneficiaries must total 100%,
including those listed on page 1). If all beneficiaries are to share equally, no percentage needs to be listed. PLEASE PRINT.
M // FF _______________________ ________________ ______
_____________________________________________ __________________ M
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
%
____________________________________________________________ ___________________________________ _______ ______________
Address
City
State
Zip
M // F
F _______________________ ________________ ______
_____________________________________________ __________________ M
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
%
____________________________________________________________ ___________________________________ _______ ______________
Address
City
State
Zip
M//FF _______________________ ________________ ______
_____________________________________________ __________________ M
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
%
____________________________________________________________ ___________________________________ _______ ______________
Address
City
State
Zip
M // F
F _______________________ ________________ ______
_____________________________________________ __________________ M
Name of Beneficiary
Spouse/Child/Other
Gender
Social Security Number
Date of Birth
%
____________________________________________________________ ___________________________________ _______ ______________
Address
City
State
Zip
SIGNATURE OF MEMBER________________________________________________________________________________ Date _____________________.
NPERS1300
Rev. 10/2012
PRINT
BAR CODE
Page ______ of ______
0.00
403(b) UNIVERSAL AVAILABILITY NOTICE
Employer: Millard Public Schools
How Can I Participate?
You can participate in the Plan with pre-tax contributions by completing and submitting a Salary Reduction Agreement
(“SRA”) online at http://www.omni403b.com/, or by submitting a completed SRA form, which can be found on the same
website, to The OMNI Group either by facsimile to (585) 672-6194 or by mail at 1099 Jay St., Bldg F, Rochester, NY,
14611 (“OMNI”).
How Much Can I Contribute Annually?
You may contribute up to $18,000 in 2015; this amount is subject to change annually. If you have at least 15 years of
service with your employer or you are at least 50 years old, you may also be able to make additional catch-up
contributions. For appropriate limits for your particular circumstances, please contact OMNI’s Customer Care Center at 1877-544-6664. Millard does not match contribution into a 403(b).
What If I Already Have An Account?
If you are already contributing to the Plan, and you want to change your contribution amount or service provider, simply
complete and submit a new SRA. See directions above for on-line and paper submission options.
How Can I Get More Information?
You can access further information at www.omni403b.com or www.403bwhyme.com.
By signing, I hereby acknowledge that I have received a Retirement Plan Benefits Overview and have been
informed of my eligibility to participate in the Plan. I understand my choice is completely voluntary and I may
change my choice to participate at any time, subject to our specific provisions.
Employee Printed Name:________________________________________ SSN:_________________
Signature______________________________________________________Date:________________
I am a CURRENT participant in a 403(b) Plan and I must complete the participation requirements above to
continue participation.
I AM interested in participating in the 403(b) Plan and would like more information.
I am NOT interested in participating in the Plan at this time.
Healthy Tomorrows
Powered by SimplyWell
Healthy Tomorrows Wellness Program 2014-2015 Summary
Congratulations! If you participated last year by completing your SimplyWell
health screening and online questionnaire, you will receive the wellness incentive
for the 2014-15 benefits plan year!
Please thoroughly read this program summary for the highlights
and details for the upcoming year!
If you wish to receive the Wellness Premium Incentive for the 2015-16 benefit
plan year, you will want to participate in the Healthy Tomorrows program this
wellness year by completing the online questionnaire and health screening by
June 1, 2015. Participating is as easy as three simple steps:
(1) Logging Into the SimplyWell website:
Current User-Employee
1. Go to www.simplywell.com
2. Log in as a current user with your user id
and password you created.
Current User-Spouse
1. Go to www.simplywell.com
2. Log in as a current user with your user id
and password you created.
New User-Employee
1. Go to www.simplywell.com
2. Log in as a new user. Your PID will be
ME plus your employee id number.
(e.g. ME54321)
New User-Spouse
1. Go to www.simplywell.com
2. Log in as new user. Your PID will be
MS plus your spouse’s employee id number.
(e.g. MS54321)
If you need log in, password or username assistance, please call the SimplyWell
customer care team at 1.877.991.9355. If you accepted emails from SimplyWell,
you may use the website for username and password assistance.
www.simplywell.com • 1.877.991. WELL (9355)
9140 West Dodge Road, Suite 408 • Omaha, Nebraska 68114
Healthy Tomorrows
Powered by SimplyWell
This year the Healthy Tomorrows Wellness Program is making it even easier for you to
be well. SimplyWell is partnering with the VNA to make flu vaccinations available for
employees and spouses at all health screenings through December 2014.
You MUST register for a location “with Flu Shot” if you wish to receive your flu shot
during your health screening. If you do not wish to receive your flu shot during your
health screening, please register for the location “without Flu Shot.” Please access the
Flu Immunization Consent listed below under the VNA Flu Immunization Registration
page link. Print and bring the consent form for your flu vaccination.
(2) Register for your Healthy Tomorrows Health Screening:
You may attend one of the following offerings, or you may utilize the Physician Upload
Form. If you use the Physician Upload option, please select ‘Health screening by
personal doctor’, and you may print the form. The form can be found on your
SimplyWell profile under the tab ‘My Information’ > ‘My Forms.’ The form is also located
on the MPS-HR website under “Wellness” tab.
Millard North High School
9/23/14*, 9/24/14*, 9/25/14*
6:30-8:30 am
Millard West High School
10/7/14*, 10/8/14*, 10/9/14*
6:30-8:30 am
Millard South High School
11/11/14*, 11/12/14*, 11/13/14*
6:30-8:30 am
RWSS
12/10/14*, 12/11/14*, 12/12/14*,
2/26/15, 2/27/15
6:30-8:30 am
DSAC
1/28/15, 1/29/15
6:30-8:30 am
Please remember to
reserve your health
screening
appointment through
your SimplyWell
profile.
*Flu Shots are available by
registering for location “with Flu
Shot”
www.simplywell.com • 1.877.991. WELL (9355)
9140 West Dodge Road, Suite 408 • Omaha, Nebraska 68114
Healthy Tomorrows
Powered by SimplyWell
(3) Complete your Health Questionnaire:
Questions?
SimplyWell Health Screening
Contact:
MPS Wellness Support Specialist
Missy Cronstrom
[email protected]
SimplyWell Log in/Password/Technical Support
Contact:
SimplyWell Customer Care
1-877-991-9355
www.simplywell.com • 1.877.991. WELL (9355)
9140 West Dodge Road, Suite 408 • Omaha, Nebraska 68114
Healthy Tomorrows
Powered by SimplyWell
Healthy Tomorrows 2014-15 Program FAQs








What is SimplyWell?
SimplyWell is a personal and confidential online health management program designed to improve your
health and reduce healthcare costs. We offer an onsite Health Screening, an online Health Risk
Questionnaire, health education tools, resources, and a detailed personal Individual Action Plan. You will be
able to access the SimplyWell online portal starting June 9, 2014.
What is a Health Screening?
An onsite Health Screening includes a comprehensive blood draw, blood pressure check and height and
weight measurements. (Fast 8-12 hours before the screening and drink plenty of water. Prescription drugs
are acceptable to take.) Onsite Health Screenings will begin in June. If you have already had a physical or
are scheduled to have a physical, you may utilize the attached Lab Results by Medical Provider form in lieu
of attending a screening. Please note, lab and biometric measurements need to have been taken between
June 1, 2014 and June 1, 2015 to qualify for this option.
What is tested in the on-site comprehensive blood draw?
The blood collected during the health screening will be tested for the following items: hemogram, lipid panel
and fasting glucose. If you purchased additional tests through the SimplyWell website, the blood collected
will be tested for that as well.
What is a Health Questionnaire?
The SimplyWell Health Questionnaire is a comprehensive set of questions about your health history and
current health. The information you provide on the questionnaire and the results from your Health
Screening are used to create your own online Health Report.
What is the deadline for completing my Health Screening and Online Health Risk Questionnaire?
Both components must be completed by June 1, 2015.
What is my online Health Report?
Your online Health Report provides detailed information on your current health status. This is a personalized
and confidential health management tool.
What is my Individual Action Plan?
SimplyWell uses your results from your Health Report and makes recommendations for you to start making
immediate changes to maintain or improve your health. You can manage Appointments and use Health
Trackers to document daily health activities from your Action Plan.
What are the benefits to participating in the SimplyWell wellness program?
You will receive a comprehensive health screening at no cost to you. Based on your health screening, you
may receive a call from a SimplyWell nurse health coach. You will have access to health libraries,
interactive health presentation and detailed health guides which cover thousands of health topics. You will
also be able to track health appointments and other important health information such as; allergies,
surgeries, medications, blood pressure, weight and much more! During the year there will be educational
seminars and exciting wellness challenges for you to participate in which may even include incentives for
your participation.
www.simplywell.com • 1.877.991. WELL (9355)
9140 West Dodge Road, Suite 408 • Omaha, Nebraska 68114
Healthy Tomorrows
Powered by SimplyWell

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






Who has access to my Personal Health Information?
You are the only person with access to your information. SimplyWell complies with all HIPPA and all
applicable federal regulations.
What is the goal of SimplyWell?
We believe information is power. By providing you with your current health status and the resources to
understand and make healthy behavior changes, we empower you to be proactive in managing your health
and making it a top priority in your life.
What are the goals of the Millard Public School’s wellness program?
The District believes our greatest resource is people. This program gives employees the opportunity to be
an active participant in their personal wellness. The goal is to have happy, healthy and engaged employees
offering the highest opportunities for our students.
What will Millard Public Schools learn about my health?
MPS will not be the recipient of any personal health information from SimplyWell. MPS will only learn if you
participated or not. SimplyWell will only share aggregate data with MPS.
Who is eligible to participate in the wellness benefit?
All MPS employee groups and spouses are eligible to participate as long as the employee is scheduled to
work a minimum of 20 hours per week.
Do I have to participate?
No, your participation is completely voluntary. Please keep in mind if you choose to participate, you will
receive an additional District contribution to your health insurance premium.
Does my spouse have to participate?
No, your spouse’s participation is completely voluntary and does not affect your health insurance premium.
Only the primary carrier of the insurance needs to participate to continue receiving the 100% paid benefit if
both you and your spouse are employed by MPS.
How much is my premium incentive for participating? This depends on your job class and your benefit
election. For some employees electing family coverage, that 2014-15 difference can be as much as
$141.08 per month ($1,692.96 per year). For persons electing employee only coverage, that 2014-15
difference may be as much as $50.03 per month ($600.36 per year). Amounts will vary depending on which
health plan you elect and your coverage election.
How does the premium differential apply to part-time employees? Part-time employees who choose to
participate in the wellness benefit can receive an additional District premium contribution prorated based on
employer contribution.
www.simplywell.com • 1.877.991. WELL (9355)
9140 West Dodge Road, Suite 408 • Omaha, Nebraska 68114
Wellness Requirements
To protect your privacy, SimplyWell does not share the questionnaire results or the health screening results
with Millard Public Schools. SimplyWell provides Millard with the information of whether or not the health
screening and/or the questionnaire is complete. Remember it is the employee’s responsibility to make sure
both requirements are complete. An easy check for completion – your SimplyWell login page should look like
the screen shot below. Your health screening and your health questionnaire should each be 100% completed.