407.4E7 - Licensed Employee Early Separation Program Election of Distribution of Early Retirement Incentive Pay

I,                                                                            , hereby elect to receive my early

retirement incentive benefit in the following manner:

_____ Placed in the trust of the district to pay single insurance premiums until agreed upon amount is exhausted; at which time I will either continue payments at my own expense, or discontinue insurance coverage.

_____ Placed in the trust of district to continue to participate in the District’s major medical insurance plan until Medicare eligible; or I am no longer permitted to continue coverage by the insurer, whichever comes first.  The District shall not be obligated to incur the cost of any additional coverage. 

If the participating employee was eligible for family coverage under the District’s major medical insurance plan or a member of the employee’s family was eligible under an additional policy; that eligibility may continue until the participant is Medicare eligible at their own expense; or they are no longer permitted to continue coverage by the insurer.  The District shall not be obligated to pay any part of the premium or expenses of the family or additional coverage.

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Signature                                                                               Date

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Witness