Annual Enrollment Forms
Enrollment Coverage Change Form: Use this form to add or delete dependents from your medical or dental insurance plans. To add a dependent you must also submit documentation of their eligibility such as a birth certificate, marriage license, tax return or other documents. Review this detailed document listing for more information. Please complete and send to Human Resources for processing.
Dependent Care Subsidy Form: If you elect to contribute to the Dependent Care Reimbursement Account you must complete this form and send it to Human Resources. If applying for a higher level subsidy you must also submit the copy of your 2017 tax return verifying your Adjusted Gross Income is less than $60,000.
Health Insurance Contribution Credit (HICC): For those employees who have lower household incomes, the cost of health insurance can be a major part of their monthly budget. The Health Insurance Contribution Credit will be available to those employees who elect either the Whole Health ACO or PPO in 2020. as follows:
|2018 Household income||
0 to 30,000
|30,001 to 45,000||
45,001 to 60,000
|Credit for Level of Income||
Bates College employees who can provide documentation of their household income in the form of the front page of their 2018 Income Tax Return will receive a credit based on the level of their income. The amount reported on your tax return as adjusted gross is used in determining your household income.
Health Savings Account Payroll Deduction Form: (you must elect the Aetna Consumer Choice (HSA) Plan to contribute to a Health Savings Account)
- If you are currently contributing to the Health Savings Account your contribution will continue into 2020 unless you change it.
- This form allows you to have additional HSA contributions deducted from your payroll. You may use this form to authorize either a one-time transaction or periodic transfers.
- Bates College will match your contributions by 50% up to a calendar year
maximum of $300 for individual coverage and $600 for Dependent Coverage.
- If you authorize periodic deductions, you may change or terminate that authorization at any time prior to the next payroll processing by completing a new form.
- Once complete this form will automatically be routed to Human Resources.