Resources

Action Required Annually for the Following:

• HRA Enrollment Form 
• HSA Application and Salary Reduction Agreement
• Certification of HSA Eligibility
• HSA Election Additional Contribution Form 2019
• FSA-DCA Enrollment Form
• Health Insurance Buyout for the 12 Month Period of January 1-2019-December 31, 2019

No Action Required Annually if you are keeping the same BC/BS insurance plan or Dental Plan

Only for New Enrollments or Changes: 

• BC/BS Enrollment/ Change Form
• Delta Dental – Enrollment – Change Form

VEHI HEALTH PLANS INFORMATION:

• BC/BS-Benefits-Booklet
• Rutland Public Schools Summary of Health Plans, HRA, HSA, and FSA
• Summary of Benefits – Platinum
• Summary of Benefits -Gold
• Summary of Benefits -Gold-CDHP with HRA Wrap Document
• Summary of Benefits – Silver-CDHP
•  BC/BS Know Before You Go
•  HSA Enrollment Book From Datapath -VT
•  FSA Enrollment Book From Datapath 2019
•  Dental Benefits Booklet

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OTHER IMPORTANT FORMS: 

•  2019-W-4 Form

•  2019-FORM W-4VT

•  FY 2019 Declaration of Health Coverage Form

•  Payroll Authorization Form

•  Short Term Leave Form 

•  Emergency Contact Form  

•  Rutland City Pension Beneficiary Form

•  VSTRS VMER Beneficiary Form

•  Rutland City School Life Beneficiary Form