Application for Full Time Employee

2017 Income Adjusted Health Insurance Subsidy

COMPLETE ONLY IF YOUR HOUSEHOLD INCOME IS LESS THAN $45,000

To be completed by Staff/Faculty Member (Please Print):

Name Davidson College ID#

My signature below indicates that I have reviewed what I/we, singly/together as a household, will earn as total income in 2017 and I certify that I have checked the appropriate household income box in the matrix below.

Check Total Estimated Household Income for 2017 / OPEN ACCESS PLAN
Check the corresponding salary adjusted subsidy
Employee / Employee & Child(ren) / Employee & Spouse / Family
 / Annual Income /  / BW / MN /  / BW / MN /  / BW / MN /  / BW / MN
less than $20,000 / $39.59 / $85.77 / $124.70 / $270.18 / $156.76 / $339.65 / $227.46 / $492.84
$20,000 - $25,000 / 34.64 / 75.05 / 109.11 / 236.41 / 137.17 / 297.20 / 199.03 / 431.24
$25,000 - $30,000 / 29.69 / 64.33 / 93.52 / 202.64 / 117.57 / 254.74 / 170.60 / 369.63
$30,000 - $35,000 / 19.79 / 42.89 / 62.35 / 135.09 / 78.38 / 169.83 / 113.73 / 246.42
$35,000 - $40,000 / 31.17 / 67.55 / 39.19 / 84.91 / 56.87 / 123.21
$40,000 - $45,000 / 28.43 / 61.61
Check Total Estimated Household Income for 2017 / HIGH DEDUCTIBLE HEALTH PLAN
Check the corresponding salary adjusted subsidy
Employee / Employee & Child(ren) / Employee & Spouse / Family
 / Annual Income /  / BW / MN /  / BW / MN /  / BW / MN /  / BW / MN
less than $20,000 / $10.15 / $22.00 / $45.13 / $97.78 / $56.74 / $122.93 / $89.22 / $193.32
$20,000 - $25,000 / 8.88 / 19.25 / 39.49 / 85.56 / 49.64 / 107.56 / 78.07 / 169.15
$25,000 - $30,000 / 7.62 / 16.50 / 33.85 / 73.34 / 42.55 / 92.20 / 66.92 / 144.99
$30,000 - $35,000 / 5.08 / 11.00 / 22.57 / 48.89 / 28.37 / 61.46 / 44.61 / 96.66
$35,000 - $40,000 / 11.28 / 24.45 / 14.18 / 30.73 / 22.31 / 48.33
$40,000 - $45,000 / 11.15 / 24.16

I further understand that the college has an obligation to be diligent in the administration of benefits, especially those regulated by the Internal Revenue Service and/or the Department of Labor. If there is question or concern about the information I have provided on this application, a representative of Human Resources can request that I authorize the IRS to verify that the total income reported on my/our 2016 federal income tax return(s) is within the range checked above. Upon such a request, I agree to authorize the IRS to verify the number or to forfeit my eligibility for the salary adjusted health insurance premium and repay what has been given me for calendar year 2017

Signature of Applicant Date