Employee Benefits

Employee Benefits

Human Resources

270 East State Street

Columbus, OH 43215

Ph. 614-365-6475

Fax 614-365-4044

Mission: Each student is highly educated, prepared for leadership and service, and empowered for success as a citizen in a global community.

The Columbus City School District does not discriminate based upon sex, race, color, national origin, religion, age, disability,
sexual orientation, gender identity/expression, ancestry, familial status or military status with regard to admission, access,
treatment or employment. This policy is applicable in all district programs and activities.

SUPPLEMENTAL INSURANCE TERMINATION FORM

The Columbus City Schools offers several supplemental benefits. This form is to terminate the established deductions for these coverage(s). Additionally, the employee will need to cancel his/her policy directly by contacting the insurance provider. Please do not fax the termination form as an original signature is required.

Please place an “X” in front of the coverage(s) that you wish to terminate.

AIG

____ Critical Care (8340)

____ Extra Term Life Insurance (8310)

COLONIAL

____ Short -Term Disability (Certified Employees Only) (8400)

HORACE MANN

____ Short -Term Disability (2610)

METLIFE

____ Long-Term Care (8330)

PET INSURANCE

____ Pet Insurance (9250)

PREPAID-LEGAL

____ Legal Services (Classified Employees Only) (9300)

____ Legal Ease (Classified Employees Only) (9350-9352)

SPECTERA

____ Vision (Will no longer be offered) (2600)

TRANSAMERICA

____ Term Life Insurance (8320)

TRUSTMARK

____ Short -Term Disability (8410)

____ Universal Life (8300)

____ Accident (2625)

____ Cancer/ Major Illness (8355)

I understand that by terminating this coverage, I am terminating my right to the above-noted supplemental

Insurance program(s) and now may not enroll except during the next “open enrollment” period.

______

Printed Name Signature Employee ID Date