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Prince William County Schools
Insurance Enrollment & Change Form
Step 1: Employee Information:
New Enrollment
Name (Last, First, Middle Initial)
Change Current Plan
Date of birth
Employee ID or Social Security Number
Street Address
City
Home Phone Number
Adding/Removing Dependent
State
Cell Phone
Zip
Sex: ____Male ____Female
Work Phone Number
Primary Care Physician ID Number (Must be completed for Healthkeepers HMO)
Effective date of coverage is 1st of the month following 30 days of employment or within 30 days of a family status change.
Step 2: Elect A Medical Plan & Coverage Level
Medical Plan Options




(Each Includes Blue View Vision)
Anthem KeyCare Enhanced (PPO)
Anthem KeyCare Core (PPO)
Anthem Healthkeepers (HMO)
Waive/Cancel Medical
Step 3: Elect Optional Dental & Vision Plan(s) & Coverage Level(s)
Dental Insurance Options

Select Medical Plan Coverage Level:





Employee Only
Employee/Child(ren)
Employee/Spouse
Family
PWCS Employees (Spouses both work for PWCS)
Step 4: List Your Dependents
Add or Remove
SPOUSE
o
o
o
Add
Remove
No Change
Add or Remove
DEPENDENTS
o
o
o
o
o
o
o
o
o
o
o
o
Add
Remove
No Change
Add
Remove
No Change
Add
Remove
No Change
Add
Remove
No Change
Spouse
(Attach copy
of marriage
certificate &
recent tax
return)

Vision Insurance Option
Delta Dental Premier
 Employee Only
 Employee/Child(ren)
 Employee/Spouse
 Family
 Waive/Cancel Dental Premier
Delta Dental PPO (In Network Only)
 Employee Only
 Employee/Child(ren)
 Employee/Spouse
 Family
 Waive/Cancel Dental PPO
Vision Service Plan
(Supplemental Plan)





Employee Only
Employee/Child(ren)
Employee/Spouse
Family
Waive/Cancel VSP
**Dental & Vision Plan elections
will result in an additional
premium charge per paycheck
First Name, MI,
Last if Different
Social Security Number
Date of Birth
Date of Marriage
Primary Care Physician ID
Number
(Must complete for
Healthkeepers HMO)
First Name, MI,
Last if Different
Social Security Number
Date of Birth
Status (Student,
Disabled, Other)
Primary Care Physician ID
Number
(Must complete for
Healthkeepers HMO)
o Male
o Female
Son or
Daughter
(Attach copy
of birth
certificate)
o Son
o Daughter
o Son
o Daughter
o Son
o Daughter
o Son
o Daughter
Check here if you use an additional form to list dependents or provide any other information requested on this page.
Step 5: Certification
As a participant in the PWCS Insurance Plan(s), I understand that I must make this election within 30 days of employment or a qualifying status change event. If I waive or cancel insurance,
the next opportunity to enroll will be during Open Enrollment (April 15 – May 15), or within 30 days of another qualifying status change. I understand that this election is made under the IRS
Section 125 Pre-Tax Rules and Regulations. I realize that any false or misrepresentation in the application may result in loss of coverage under the policy. I certify that the information I have
provided on this application is complete and true to the best of my knowledge.
 Signature:
Date:
P.O. Box 389, Manassas, VA 20108 WWW.PWCS.BENEFITS.SCHOOLFUSION.US703.791.8050888.797.4473 FAX 703.791.8906
Rev 04/01/2015
How to Fill Out the Insurance Enrollment & Change Form
PRINT requested information.
If You Are:

A new enrollee, complete all sections. A New enrollee is a new employee or a current employee who is not currently enrolled in a PWCS
insurance plan. For new employees, newly elected medical benefits, and optional dental and vision plans are effective the first of the
next month following 30 days of employment. Benefits take effect July 1 for current employees who apply during open enrollment. If a
family status change occurs, the effective date is determined by the documentation provided. Documentation must be received within
30 days of the family status change.

Currently enrolled in a plan(s) but switching to a different plan(s), complete all sections.

Currently enrolled in a plan but canceling coverage, complete sections 1 and 5

Currently enrolled in a plan but changing your information on file by adding or removing a dependent, complete all sections.
 Step 1 – Your Information
All employees should complete this section.
 Step 2 – Elect a Medical Plan & Coverage Level
Complete this section if you wish to enroll in one of the medical plans. The medical plan automatically includes Blue View Vision through
Anthem. Dental Insurance must be elected separately.
o Select one plan
o Select coverage level for plan selected
 Step 3 – Elect Dental and Vision Plan(s) & Coverage Level(s)
Complete this section if you wish to enroll in the Delta Premier (In and Out of Network PPO) and/or the Delta PPO (PPO - Provider
Network Only) dental policies or the supplemental Vision Service Plan (VSP) vision policy.
o You may select either Delta Premier, Delta PPO, or both dental plans independent of any other plan
o You may select the Supplemental Vision Insurance Option (Vision Service Plan) independent of any other plan
o Select the coverage level for the plan selected
 Step 4 – List Your Dependents
List any dependents (your spouse and children) you wish to cover or remove. Documentation that verifies your dependent’s eligibility
(your marriage certificate & copy of the front page of your previous year’s federal tax return that includes your spouse’s name), birth
certificate, adoption papers, court order) must be submitted with your application. PWCS covers dependents until age 26 if they are not
eligible for insurance benefits through their employer. If you have additional dependents to list, attach a separate page with the
requested information.
o If you add someone who is not eligible, you are responsible for claims paid and coverage is canceled back to the effective date.
o If you list a son or daughter who is over the maximum age (26) and disabled, you must contact the Office of Benefits &
Retirement Services.
o Primary Care Physician – You must list a primary care physician ID number (6 digit number not the name) for each family
member if you are enrolling in the Healthkeepers HMO. You can obtain physician provider lists and ID numbers through the
Anthem Provider director Link on the Benefits Web Page. If you do not list a physician ID number, the Healthkeepers HMO will
assign a physician to each member on the plan.
 Step 5-Your Signature and Date
Sign and date your form.
 Submit Your Forms
If it is not Open Enrollment and you are making a midyear change, you should also submit the Documentation for Midyear Benefit
Changes form (and accompanying documentation for your change). Forms are available at www.pwcs.benefits.schoolfusion.us.
Please note that you may only:
Enroll (unless you are a new employee), Change plans, or Add or remove a dependent during Open Enrollment, which is
April 15 to May 15 each year. However, if you experience a qualified status change any other time during the calendar year, such as marriage, the
birth or adoption of a child, or your spouse or a dependent loses or obtains medical coverage elsewhere, you may make certain changes to your
coverage consistent with the event, within 30 days of the event. Other than during Open Enrollment, changing plans typically is allowed only when
you have moved out of the service area for your plan. You can call the Office of Benefits & Retirement Services at 703.791.8050 or 1.888.797.4403
for more information.
Prince William County Schools
Health, Dental and Vision
Employee Payroll Deduction Form
FY 2015-2016
12 Month Paid Employees
MEDICAL PLANS
Employee Only
Employee & Children
Employee & Spouse
Employee & Family
SB Family/SB Spouse
Employee Only
Employee & Children
Employee & Spouse
Employee & Family
SB Family/SB Spouse
Employee Only
Employee & Children
Employee & Spouse
Employee & Family
SB Family/SB Spouse
10 Month Paid Employees
Full-time Per Pay Period Part-time Per Pay Period Full-time Per Pay Period
Deduction
Deduction
Deduction
KeyCare Enhanced PPO/Blue View Vision
$
53.65 $
173.82 $
67.77
$
210.45 $
370.22 $
265.83
$
245.05 $
430.02 $
309.53
$
346.90 $
613.95 $
438.19
$
107.30 $
347.64 $
135.54
KeyCare Core PPO/Blue View Vision
$
26.65 $
146.82 $
33.66
$
162.95 $
322.72 $
205.83
$
190.05 $
375.02 $
240.06
$
267.90 $
534.95 $
338.40
$
53.30 $
293.64 $
67.32
Healthkeepers HMO/Blue View Vision
$
12.65 $
132.82 $
15.98
$
136.95 $
296.72 $
172.99
$
158.55 $
343.52 $
200.27
$
228.90 $
495.95 $
289.14
$
25.30 $
265.64 $
31.96
12 Month Paid Employees
DENTAL / VISION PLANS
Employee Only
Employee & Children
Employee & Spouse
Employee & Family
SB Family/SB Spouse
Employee Only
Employee & Children
Employee & Spouse
Employee & Family
Employee Only
Employee & Children
Employee & Spouse
Employee & Family
Full-time Per Pay Period Part-time Per Pay Period
Deduction
Deduction
Delta Dental Premier Plan
$
0.86 $
9.10
$
10.40 $
22.53
$
9.93 $
21.52
$
15.40 $
33.36
$
1.72 $
18.20
Delta Dental PPO Plan
$12.83
$27.91
$24.43
$43.66
Supplemental Vision Service Plan
$4.48
$5.68
$5.55
$9.11
Part-time Per Pay Period
Deduction
$
$
$
$
$
219.57
467.65
543.19
775.51
439.14
$
$
$
$
$
185.46
407.65
473.72
675.72
370.92
$
$
$
$
$
167.78
374.81
433.93
626.46
335.56
10 Month Paid Employees
Full-time Per Pay Period
Deduction
Part-time Per Pay Period
Deduction
$
$
$
$
$
$
$
$
$
$
1.09
13.13
12.55
19.45
2.18
11.49
28.46
27.18
42.15
22.98
$16.21
$35.25
$30.86
$55.15
$5.65
$7.17
$7.01
$11.51
Additional Enrollment Information
1 The effective date of coverage for new employees is the first of the month following 30 days of employment. For example, if you are hired Aug. 21 your effective date is Oct.
1. If a family status change occurs, the effective date is determined by the documentation provided.
2 PWCS insurance is paid one month in advance. Depending on the effective date you may owe additional premiums to get on schedule. If you owe additional premiums, you
may elect that they be divided and equally witheld from:
(Select one) ______One _______Two _______ or Three pay checks.
3 If your spouse also works for PWCS, please enter the spouses name and SSN below.
Spouse's Name _________________________________________________
Spouse's SSN ___________________________________
Waiver/Declining Coverage
I elect NOT to ENROLL in PWCS Group Health Insurance Program.
My spouse is employed with PWCS and I am a dependent on his/her policy. I elect NOT to ENROLL separately.
Acknowledgement
By signing below, I authorize the premium deductions be withheld pretax per pay. I understand that I am not able to make changes or cancel this insurance election until the
open enrollment period (April 15-May 15) or within 30 days of a qualifying status change, as defined by the Department of Treasury.
Print Name: __________________________________________________
Employee Signature:___________________________________________
SSN: ________________________________
Date: ________________________________
If enrolling, an Insurance Enrollment & Change Form must accompany this form.
RETURN COMPLETED FORMS TO THE OFFICE OF BENEFITS & RETIREMENT SERVICES
Rev. 04/01/2015