Fringe Benefits-Employee Forms

Benefit Enrollment Guides (Posted 11/4/2021):

Open Enrollment for Health Benefits is open from November 15th, 2021 thru December 3rd, 2021.  Please Click the link that matches your position with Wyandotte Public Schools, read the guide and follow the instructions.

If you have questions and want to schedule a virtual appointment with a representative from Gallagher, please contact Beth Bishoff via email at beth_bishoff@ajg.com

INSURANCE PLAN SUMMARIES:

• Administrators (PDF)(20PP, 6.89MB)
• Teachers (PDF)(20PP, 5.48MB)
• Administrative Assistants (20PP, 6.46MB)
• Maintenance (PDF)(20PP, 5.48MB)
• Paraprofessionals (PDF)(20PP, 5.50MB)

HEALTH COVERAGE INFORMATION - BLUE CROSS:

• Affordable Care Act 
• Change of Status(PDF) See Page 6 (9PP, 800KB)
• Employee Enrollment Form (PDF) See Page 2(9PP, 800KB)
• Health Savings Account (HSA) Enrollment Form - 2021 (PDF) (1PP, 265.51KB)
• Health Savings Account (HSA) Enrollment Form - 2022(PDF) (1PP, 265.51KB)
• Michigan No-Fault Auto Insurance Change Letter (PDF) (1PP, 391KB)

DENTAL COVERAGE INFORMATION - ADN:

• Plan Information(PDF)(20PP, 6235KB)
• Enrollment/Change Form(PDF)(1PP,399KB)

PRESCRIPTION COVERAGE INFORMATION - MEDTIPSTER:

• Claim form - Prescription Form (PDF)(1PP, 396KB)

VISION COVERAGE INFORMATION:

• Optical Enrollment/Change Form (PDF)(1PP, 509KB)

LIFE INSURANCE COVERAGE INFORMATION - MADISON NATIONAL:

• Change of Beneficiary Form (PDF)(2PP, 1041KB)
• Employee Assistance Program (EAP)(567KB)
• Enrollment Form (PDF) (1PP, 416KB)

VOLUNTARY BENEFITS 

• Trustmark (PDF) (1PP, 79KB)
• Unum(PDF)(2PP,104KB)

FLEXIBLE SPENDING ACCOUNT INFORMATION - Employee Benefits Concepts:

2021 Plan Year Information:

• MyFlexOnline  
• What is an FSA?(PDF)(2PP,434KB)
• Sign up Now (PDF)(1PP, 418KB)
• ​FSA Expense List (PDF)(2PP, 593KB)
• Daycare(PDF) (1PP,383KB)
• Dependent Care Reimbursement Form(PDF) (1PP, 712KB)
• Elder Care(PDF)(1PP, 384KB)
• Medical Expense Reimbursement Form (PDF) (1PP, 464KB)
• WPS Debit Card (PDF) (2PP, 1174KB)
• Understanding Agreement(PDF) (1PP,37KB)
• WPS 2022 Election Form (PDF) (1PP, 214KB)

2022 Plan Year Information:

• Group Resources-Summit  
• What is an FSA?(PDF)(2PP,131KB)
• Sign up Now (PDF)(1PP, 418KB)
• ​FSA Expense List (PDF)(2PP, 593KB)
• Daycare(PDF) (1PP,383KB)
• Dependent Care Reimbursement Form(PDF) (1PP, 712KB)
• Elder Care(PDF)(1PP, 384KB)
• Medical Expense Reimbursement Form (PDF) (1PP, 464KB)
• WPS Debit Card (PDF) (2PP, 1174KB)
• Understanding Agreement(PDF) (1PP,37KB)
• WPS 2022 Election Form (PDF) (1PP, 214KB)