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Welcome to Pickerington Local School District

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Welcome to Pickerington Local School District
Welcome to Pickerington Local School District
90 N. East Street, Pickerington, Ohio 43147
Please complete each applicable form as indicated below. Contact the Payroll Department to
schedule an appointment. Your forms are due back to the district office by ______________.
As a new employee of Pickerington Local Schools I am sure you have many questions and you
are not sure who to ask or where to find the answers. There are many forms and information
necessary before you can be added to our payroll. I hope you will find this information helpful
in answering many of your questions.
Attached is a New Employee Packet which includes the following forms. These items must be
submitted before you can be added to our payroll system.
MANDATORY
Fingerprints
 Official College Transcript(s) (Certified Staff)
 Copy(s) of all current teaching certificates (Certified Staff)
 NTE/PPST results (Certified Staff)
 City Tax Form (Directory Information and Tax Liability)
 Ohio New Hire Reporting Form
 Employment Eligibility Verification & proper ID (one piece of ID needs to have social security number
listed)
 Acknowledgement of COBRA notice
Federal Tax Form W-4
 State Tax Form IT-4
 Direct Deposit Form (Mandatory)
 Retirement System Application - School Employees (SERS) or State Teachers (STRS)
 Social Security Form
 AF Enroll On-Line enrollment information
 Insurance Opt-Out Form (with supporting documentation if applicable)
 Health Insurance Marketplace Coverage Options
 FILE: GBP Drug-Free Workplace (initial page)
 FILE: GBK Smoking On School Premises By Staff Members (initial page)
 Disability Questionnaire
 Annuity/Ohio Deferred Comp Info

OPTIONAL
 3 for 3 donation form
INSURANCE
Information is enclosed which explains the insurance programs available to employees of
the district. These are for your use and need not be returned.
If you intend to apply for family insurance coverage, you must provide one of the following
for each dependent to verify dependent eligibility:
1. Page 1 of your most recently filed Federal 1040 tax return (with income amount
redacted (blacked-out)
2. Official birth certificates
3. Adoption paperwork
4. Court Order
5. Marriage Certificate
At your new hire meeting with payroll, you will have the opportunity to enroll in coverage online, or you may choose to enroll on your own by following the instructions included in your
packet. Please remember that you must enroll within 30 days of your hire date.
Health/Dental insurance is effective the 1st day of the month following your employment
date.
If you elect to waive coverage, you will only be able to apply for coverage during the open
enrollment period (each August, effective September 1). Any new dependent(s) must be added
to a family policy within thirty (30) days by updating your benefit information in AF Enroll online.
CLASSIFIED STAFF/ADMINISTRATORS ONLY: You have 2 options for health insurance coverage.
A traditional PPO or a High Deductible Health Plan. Please see the enclosed information for
details.
Life Insurance
The Board of Education pays complete life insurance for all employees. This program provides
$40,000 of group term life insurance for the employee.
When Will I Receive My First Pay Check?
Prior to being paid by Pickerington Local Schools the employee must be hired by the Board of
Education. Employees are paid the 5th and 20th of the month, 24 time per year. If pay dates fall
on the weekend, you will be paid the Friday before. Depending on whether you are a
Contracted Employee or a Time Sheet Employee, it will determine when you will receive your
first pay. Every attempt is made to pay you on the next scheduled pay date after you begin
working. However, on occasion coordination of the board meeting date when approval for
hiring takes place, the employee’s start date, and paperwork processing can cause an
unavoidable delay in the first pay.
Direct Deposit
Contracted employees are required to receive their pay through direct deposit. You must
complete a direct deposit form and supply the payroll office with a voided check or
documentation through your bank to get this set up. You will receive your stub by first class
email. Your pay will be held until this information is provided.
SICK LEAVE TRANSFER
Personnel new to the Pickerington Schools, having accumulated sick leave in other appropriate
Ohio employment, may transfer a maximum of 120 days to the Pickerington Schools. You must
request this transfer from your previous employer, and when received, it will be placed in your
permanent record folder. Your sick leave balance will also appear on your direct deposit
notification, so that you can check it for accuracy.
Payroll Errors
We strive to make sure that errors do not happen; however, there are times when we do have
to deal with this situation. All errors will be corrected on the payroll that follows the pay in
which the error occurred.
STRS/SERS
All school districts in Ohio pay into either State Teachers Retirement System for certified staff
or School Employees Retirement System for classified staff. We do not pay into Social Security
for retirement purposes.
Mandatory Deductions
By law, you are required to pay the following deductions:
- State Teachers Retirement System (certified staff only)
- School Employees Retirement System (classified staff)
- Federal Taxes
- State Taxes
- Medicare – 1.45% of gross per pay
- City taxes where you work and live
- School district tax where you live
Collecting City Income Taxes
Pickerington Local Schools collects and pays city taxes to the city in which you work and live. If
you live in another city that requires you to pay city income tax, you will need to provide the
payroll department with that information.
Ohio School District Income Tax
If you live in a school district that collects a school district income tax, you must provide this
information to the payroll department. If the rate changes at any time, it is your responsibility
to notify the payroll department of that change.
Fiscal Department Staff
Timothy (Ryan) Jenkins-Treasurer
Keltah Houser-Siders-Assistant Treasurer
Rick Knapp-Payroll/Benefits Coordinator
Judy Entinger-Payroll (Classified/Supplementals)
Lora Hunt-Payroll (Certified/Sub Teachers)
Tereasa Thacker-Swanson-Accounts Payable
Becky Dellinger-Budgetary
Gloria McDaniel-District Cashier
Amanda Forsbach-Administrative Secretary
614-834-2140
614-834-2147
614-834-2148
614-834-2138
614-834-2144
614-834-2142
614-834-2146
614-834-2141
614-834-2137
Making Changes in Contact Information
Please complete an address change form with address, phone number, name change, and tax
liability information to the Treasurer’s Office. The form is provided in your building office or at
the Treasurer’s Office.
Your pay may be delayed unless all the above forms/documents are submitted
to the Treasurer’s Office.
Questions may be directed to the Payroll Department.
Important Contacts
Treasurer’s Office
Judy Entinger – Payroll (Classified and Supplemental Staff)
[email protected] / 614.834.2138
Lora Hunt – Payroll (Certified Staff and Substitute Teachers)
[email protected] / 614.834.2144
Rick Knapp – Payroll and Benefits Coordinator
[email protected] / 614.834.2148
Human Resources
Vicki Baptist – Administrative Secretary Human Resources Department
[email protected] / 614.834.2162
Nichole Walters – Administrative Secretary Human Resources Department
[email protected] / 614.834.2159
IT 4
Rev. 5/07
Notice to Employee
1. For state purposes, an individual may claim only natural dependency exemptions. This includes the taxpayer, spouse
and each dependent. Dependents are the same as defined
in the Internal Revenue Code and as claimed in the taxpayer’s
federal income tax return for the taxable year for which the
taxpayer would have been permitted to claim had the taxpayer filed such a return.
2. You may file a new certificate at any time if the number of your
exemptions increases.
You must file a new certificate within 10 days if the number of
exemptions previously claimed by you decreases because:
(a) Your spouse for whom you have been claiming exemption is divorced or legally separated, or claims her (or his)
own exemption on a separate certificate.
(b) The support of a dependent for whom you claimed exemption is taken over by someone else.
(c) You find that a dependent for whom you claimed exemption must be dropped for federal purposes.
The death of a spouse or a dependent does not affect your
withholding until the next year but requires the filing of a new
certificate. If possible, file a new certificate by Dec. 1st of the
year in which the death occurs.
For further information, consult the Ohio Department of Taxation, Personal and School District Income Tax Division, or
your employer.
3. If you expect to owe more Ohio income tax than will be
withheld, you may claim a smaller number of exemptions;
or under an agreement with your employer, you may have
an additional amount withheld each pay period.
4. A married couple with both spouses working and filing a
joint return will, in many cases, be required to file an individual estimated income tax form IT 1040ES even though
Ohio income tax is being withheld from their wages. This
result may occur because the tax on their combined income will be greater than the sum of the taxes withheld
from the husband’s wages and the wife’s wages. This
requirement to file an individual estimated income tax form
IT 1040ES may also apply to an individual who has two
jobs, both of which are subject to withholding. In lieu of
filing the individual estimated income tax form IT 1040ES,
the individual may provide for additional withholding with
his employer by using line 5.
✁ please detach here
hio
Department of
Taxation
Print full name
IT 4
Rev. 5/07
Employee’s Withholding Exemption Certificate
Social Security number
Home address and ZIP code
Public school district of residence
(See The Finder at tax.ohio.gov.)
School district no.
1. Personal exemption for yourself, enter “1” if claimed ...............................................................................................................
2. If married, personal exemption for your spouse if not separately claimed (enter “1” if claimed) ............................................
3. Exemptions for dependents .......................................................................................................................................................
4. Add the exemptions that you have claimed above and enter total ...........................................................................................
5. Additional withholding per pay period under agreement with employer ..................................................................................
$
Under the penalties of perjury, I certify that the number of exemptions claimed on this certificate does not exceed the number to which I am entitled.
Signature
Date
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32
Statement Concerning Your Employment in a Job
Not Covered by Social Security
Employee Name
Employee ID#
Employer Name
Employer ID#
Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you
may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social
Security based on either your own work or the work of your husband or wife, or former husband or wife, your
pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will
not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be
affected.
Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a
modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As
a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For
example, if you are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of
this provision is $313.50. This amount is updated annually. This provision reduces, but does not totally eliminate,
your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall
Elimination Provision.”
Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you
become entitled will be offset if you also receive a Federal, State or local government pension based on work
where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or
widow(er) benefit by two-thirds of the amount of your pension.
For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security,
two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are
eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100).
Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still
eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government
Pension Offset.”
For More Information
Social Security publications and additional information, including information about exceptions to each provision,
are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard of
hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.
I certify that I have received Form SSA-1945 that contains information about the possible effects of the
Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social
Security benefits.
Signature of Employee
Form SSA-1945 (12-2004)
Date
Online Enrollment Instructions
Pickerington Local School District
Online Benefits Enrollment
Enrollment Begins August 10th
The online enrollment site will be open August 10th through September 11th. During this time, you will be able to enroll in your
benefits for the upcoming plan year. The online enrollment site allows you convenient access to enroll in your benefits at anytime, whether
at work or at home. Please follow the instructions below to get started.
How To Login
1. To access the online enrollment system, go to:
www.afenroll.com/enroll
2. At the login screen, you will login using the following
information:
• Type in your Social Security Number (SSN).
• Your PIN is the last four digits of your SSN and last two of
your birth year. (For example, for SSN# 123-45-6789 and
birth year 1974, you would type in 678974).
3. Click the ‘Log on’ button.
4. Follow the AF Enroll Guide instructions found
on the PLSD Website or in Google Drive.
Helpful Tips
• If you leave the system in the middle of the enrollment,
click the “Logout” button and all of your confirmed
selections will be saved. When you return you can
scroll your mouse over the menus at the top of the
screen to easily navigate throughout the site.
• Print your Enrollment Confirmation. Once you confirm
your entire enrollment, you can click on the Enrollment
Confirmation link at the bottom of the Sign/Submit
Complete screen to print your confirmation statement.
• You can re-enter the enrollment system to make
changes any time during your enrollment period.
• If you wish to elect no benefits, you must enter each
product module and make that choice.
• Social Security Number is required for all employees
and their dependents.
• If you are adding a dependent as a beneficiary, their
Social Security Number is required.
• Date of Birth is required for all employee and their
dependents.
• Your PIN is your electronic signature. You will use
your PIN to confirm applications and your enrollment
confirmation.
Have Questions or Need Help?
Contact Jonny Leonard your American Fidelity Manager, for more
information on enrolling in your benefits.
Call 877-518-2337, ext. 725 or email [email protected]
americanfidelity.com.
2000 N. Classen Boulevard • Oklahoma City, Oklahoma 73106
M-3388-1014_Pickerington Local School District
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Your Summary of Benefits
Pickerington Local School District
Lumenos Health Savings Accounts Option 4
Effective 09/01/2015
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal
health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and
Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits.
Covered Benefits
Network
Single: $1,500
Deductible
Family coverage requires the family deductible to be met before coinsurance Family: $3,000
applies. The single deductible does not apply to family coverage.
Network and Non-Network deductibles are combined.
(This only applies to non-embedded deductible designs.)
Single: $3,000
Out-of-Pocket Limit
Family: $6,000
10% / 10%
Physician Home and Office Services (PCP/SCP)
Primary Care Physician(PCP)/Specialty Care Physician (SCP)
· Including Office Surgeries, allergy serum, allergy injections and allergy
testing
Preventive Care Services
Services include but are not limited to:
Routine Exams, Pelvic Exams, Pap testing, PSA tests, Immunizations,
Annual diabetic eye exam, Routine Vision and Hearing exams, Routine
Mammograms, Diabetic Self Management Training, and Certain Medical
Nutritional Therapy (Network only).
· Physician Home and Office Visits (PCP/SCP)
No Cost Share
· Other Outpatient Services @ Hospital/Alternative Care Facility
Emergency and Urgent Care
10%
· Emergency Room Services @Hospital
(facility/other covered services)
(copayment waived if admitted)
10%
· Urgent Care Center Services
10%
Inpatient and Outpatient Professional Services
Include but are not limited to:
· Medical Care visits (1 per day), Intensive Medical Care, Concurrent
Care, Consultations, Surgery and administration of general anesthesia and
Newborn exams
10%
Inpatient Facility Services
Unlimited days except for:
· 60 days Network/Non-Network combined for physical medicine / rehab
(limit includes Day Rehabilitation Therapy Services on an outpatient basis)
· 100 days Network/Non-Network combined for skilled nursing facility
10%
Outpatient Surgery Hospital / Alternative Care Facility
· Surgery and administration of general anesthesia
10%
Other Outpatient Services (including but not limited to):
· Non Surgical Outpatient Services
For example: MRIs, C-Scans, Chemotherapy, Ultrasounds and other
diagnostic outpatient services.
· Home Care Services (Network/Non-network combined)
100 visits (excludes IV Therapy)
· Durable Medical Equipment, Orthotics, and Prosthetics
· Physical Medicine Therapy Day Rehabilitation programs
· Hospice Care
10%
· Ambulance Services
10%
Non-Network
Single: $1,500
Family: $3,000
Single: $6,000
Family: $12,000
30%
30%
30%
10%
10%
30%
30%
30%
30%
10%
10%
Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company
An independent licensee of the Blue Cross and Blue Shield Association.
® Registered marks Blue Cross and Blue Shield Association.
Anthem: 113648 -HSA Lumenos Page: 1
Your Summary of Benefits
Pickerington Local School District
Lumenos Health Savings Accounts Option 4
Effective 09/01/2015
Covered Benefits
Outpatient Therapy Services
(Combined Network & Non-Network limits apply)
· Physician Home and Office Visits (PCP/SCP)
· Other Outpatient Services @ Hospital/Alternative Care Facility
Limits apply to:
· Physical therapy: 20 visits
· Occupational therapy: 20 visits
· Manipulation therapy: 12 visits
· Speech therapy: 20 visits
Behavioral Health Services:
Mental Health and Substance Abuse (1)
· Inpatient Facility Services
· Physician Home and Office Visits (PCP/SCP)
· Other Outpatient Services @ Hospital/Alternative Care Facility
Human Organ and Tissue Transplants
· Acquisition and transplant procedures, harvest and storage.
Prescription Drugs:
· Network Retail Pharmacies:
(30-day supply)
Includes diabetic test strip
· Anthem Mail Service:
(90-day Supply)
Includes diabetic test strip
Network
Non-Network
10% / 10%
10%
30%
30%
10%
10% /10%
10%
10%
30%
30%
30%
30%
10%
30%(2)
10%
Not Covered
Notes:
· All deductibles and coinsurance apply toward the out-of-pocket maximum including prescription drugs. (Excludes Non-network Human Organ and
Tissue Transplants).
· Deductible(s) apply only to covered medical services listed with a percentage (%) coinsurance including prescription drugs.
· Network and Non-network deductibles are combined. Network and Non-network coinsurance and out-of-pocket maximums are separate and do not
accumulate toward each other.
· Dependent age: to the end of the month in which the child attains age 26.
· 0% means no coinsurance up to the maximum allowable amount. However, when choosing a Non-network provider, the member is responsible for any
balance due after the plan payment.
· PCP is a Network Provider who is a practitioner that specializes in family practice, general practice, internal medicine, pediatrics, obstetrics/
gynecology, geriatrics or any other Network provider as allowed by the plan.
· SCP is a Network Provider, other than a Primary Care Physician, who provides services within a designated specialty area of practice.
· Benefit period = Calendar Year
· Behavioral Health: Mental Health and Substance Abuse benefits provided in accordance with Federal Mental Health Parity.
· Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are
covered.
(1) We encourage you to refer to the Schedule of Benefits for limitations.
(2)Rx non-network diabetic/asthmatic supplies not covered except diabetic test strips.
Precertification:
· Members are encouraged to always obtain prior approval when using Non-network providers. Precertification will help avoid any unnecessary reduction
in benefits for non-covered or non-medically necessary services.
Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company
An independent licensee of the Blue Cross and Blue Shield Association.
® Registered marks Blue Cross and Blue Shield Association.
Anthem: 113648 -HSA Lumenos Page: 2
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PICKERINGTON LOCAL SCHOOL DISTRICT
INSURANCE OPT-OUT INCENTIVE
***Form due to Treasurer’s Office by September 28th***
_____________________________________________________________________________________________________________
The Board will pay an annual Opt-Out Incentive to employees who opt-out of the Board’s major medical health insurance plan on or before and
effective date of September 1st of each year. The opt-out incentive shall be paid as follows:
2015-2016
Family Plan: $4,200
Single Plan: $2,400
The lump sum payment shall be made in the last pay in June of each school year.
**SPECIAL NOTICE FOR THE 2015-2016 SCHOOL YEAR: DUE TO THE FACT THAT SETTLING THE NEGOTIATED AGREEMENT(S) TOOK LONGER THAN
ANTICIPATED, OPEN ENROLLMENT FOR THE PLAN YEAR STARTING SEPTEMBER 1, 2015, WILL BE HELD IN SEPTEMBER OF 2015. IF YOU CURRENTLY
ARE ON THE DISTRICT’S INSURANCE PLAN, BUT THINK THAT YOU WILL BE OPTING OUT PRIOR TO THE DEADLINE OF SEPTEMBER 28TH, BE AWARE
THAT THE OPT-OUT EFFECTIVE DATE WILL BE SEPTEMBER 1, 2015. THIS MEANS THAT IF YOU CHOOSE TO OPT-OUT AFTER SEPTEMBER 1, BUT
BEFORE THE DEADLINE OF SEPTEMBER 28, YOU WILL NOT HAVE COVERAGE IN THE MONTH OF SEPTEMBER—BE ADVISED THAT ANY CLAIMS
YOU MIGHT INCUR IN THE MONTH OF SEPTEMBER WOULD THEN NOT BE COVERED.
If coverage is dropped for less than twelve (12) months, the incentive payment will be based on the number of whole months during the contract
year for which coverage was dropped.
For part-time employees, the opt-out incentive will be prorated to reflect the proportion of a full-time equivalent (FTE) position held by the
employee. All part-time employees must be eligible for health insurance to opt-out. Article 11 of the agreement with the PEA specifies which parttime unit members are eligible. Administrative and classified employees must work at least 4 hours per day to qualify for the opt-out incentive.
In order to be eligible to receive the opt-out incentive, the employee must stay off the Board’s major medical health insurance plan from
September 1st through the remainder of that contract year. However, if the employee experiences a qualifying event (including, but not limited to
the employee’s spouse losing his/her job) then, in such event, the employee will be eligible to immediately resume his/her health insurance
coverage through the Board. The employee’s opt-out incentive will be prorated to reflect the percentage of a full contract year that the employee
was off the PLSD Board’s health plan. Submissions will be pro-rated in the month the paperwork was received.
If the employer of the spouse of an employee has a health insurance open enrollment period that begins after September 1st, then the employee
may opt-out of the Board’s health insurance plan through the remainder of that contract year. In such event, the above-referenced health
insurance opt-out incentive would be prorated to reflect the percentage of a full contract year that the employee stays off the Board’s health plan.
In no instance will an employee be paid the Opt-Out Incentive if he/she is covered by a spouse or parent who is provided Board paid major
medical health insurance.
INITIAL OPT-OUT REQUIREMENTS
In the case of an employee who is opting out of the health plan for the first time and has never had the District’s health care plan in the past, and
where that employee is seeking the opt-out payment for a family plan, that employee must include with the opt-out forms proof that he/she is
eligible for a family plan. Acceptable proof shall consist of the following:
• For a spouse: copy of marriage license AND copy of the most recently filed tax return confirming the spouse as a dependent (please
redact financial information)
• For a child or minor dependent: copy of a birth certificate(s) naming employee/spouse as the child’s parent/legal guardian; in the case of
adoption, copy of adoption papers naming the employee/spouse as the child’s parent(s); copy of the appropriate legal documentation
naming the employee/spouse as the child’s parent/legal guardian
• Anthem Insurance Application - Complete Section 11 - Waiver of Coverage listing employee and or dependents waiving coverage with
Employee’s Signature. Applies to both single or family coverage**
___________________________________________________________________________________________
Initial Opt-Out
• Date to drop coverage: _______/_______/________
• Type of Coverage (circle one):
Single **/ Family**
• Employee name (please print): __________________________________________________ Employee ID:_____________________
Continue Opt-Out from previous year 2014-2015.
• Employee name (please print): __________________________________________________ Employee ID:_____________________
*If you are seeking to continue a family opt-out option, please submit a copy of the most recently filed tax return
(redact the financial information) confirming the dependent status of your spouse and/or child to qualify for family.
Otherwise, a single opt-out will be applied.
Employee’s Signature ________________________________________ Date ____________________
Pickerington Local School District
90 East Street
Pickerington, Ohio 43147
TO:
New Employees
FROM:
Treasurer’s Office
RE:
Continuation of Insurance Benefits
Federal Law, which is part of the Consolidated Omnibus Budget Reconciliation Act
(COBRA), requires employers with 20 or more employees to continue offering group
health insurance coverage to terminated employees and their dependents and to
divorced, separated or widowed spouses and dependents of employees.
Benefits can be extended for an eighteen month period to employees and their
dependents when coverage normally would end as a result of that employee’s
voluntary termination, reduction in work hours, layoff for economic reasons, and discharge for misconduct (except for gross misconduct).
A thirty-six month continuation of benefits is offered to children of current employees
who lose eligibility because of age, surviving spouses and children of deceased
employees, and separated, divorced or Medicare-ineligible spouses and children of
current employees.
Please acknowledge receipt of this notification by signing and returning the attached
statement to the Treasurer’s Office.
Thank you for your cooperation.
*************************************************************************************************
As an employee of the Pickerington Local School District, I acknowledge receipt of this
notice of option for continuation of group insurance benefits.
_______________________________
Signature
Cont. Ins. Benefits 97
_______________________
Date
TO:
FROM:
PICKERINGTON LOCAL SCHOOL DISTRICT
New Employees
Treasurer’s Office
We are required by the Industrial Commission of Ohio to submit an annual report listing those persons
who are handicapped as defined in Section 4123.343(A) of the Revised Code.
Please note that discrimination on the basis of a handicap which does NOT create an occupational
hazard, nor prevents substantial job performance is prohibited by State law.
All information from this survey will be kept confidential and at the District Office. The information
from the survey will be used only for the reasons given. Your cooperation in completing this survey is
sincerely appreciated. Please contact me at the District Office should you have any questions.
Please complete the following by circling one answer for each of the 25 listings:
1.
2.
3.
YES
YES
YES
NO
NO
NO
4.
YES
NO
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
15.
16.
17.
18.
19.
20.
21.
22.
23.
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
24.
25.
YES
YES
NO
NO
Signature
Epilepsy (chronic nervous disorder/seizures/unconsciousness)
Diabetes (sugar)
Cardiac Disease (heart disorders/high blood pressure, previous heart
attack, murmur, etc.)
Arthritis (joint inflammation – almost anyone who has suffered from bone
and joint injuries, or chronic pain in joints and disc space narrowing; commonly
in those over 40 years of age, a result of the general aging process)
Amputated foot, leg, arm, hand
Partial or complete loss of vision (more than 75% bilaterally)
Residual disability for Poliomyelitis (Polio)
Cerebral Palsy
Multiple Sclerosis
Parkinson’s Disease
Cerebral Vascular Accident (CVA-stroke)
Tuberculosis (TB)
Silicosis (lung disease caused by silica dust, i.e., from foundaries)
Psychoneurotic Disability (previous psychiatric care, treatment for
depression, etc.)
Hemophilia (bleeder)
Osteomyelitis (infection of bone)
Ankylosis (stiff or frozen joints)
Hyperinsulinism (low sugar)
Muscular Dystrophies (MS)
Arteriosclerosis (hardening of the arteries)
Thrombophlebitis (vein inflammation)
Varicose veins
Cardiovascular, pulmonary, or respiratory disease of a fire fighter or
police officer employed by a municipal corporation or township.
Coal Miners Pneumonoconiosis (Black Lung Disease)
Employees who have successfully completed an Industrial Commission
Rehabilitation Program.
Date
Building
File: GBP
INITIAL__________
DRUG-FREE WORKPLACE
The Board endeavors to provide a safe workplace for all employees realizing that the use/abuse of
drugs and alcohol can endanger the health, safety and well-being of the nonuser, as well as the
user.
Because of the Board’s commitment to provide a safe workplace, no employee shall unlawfully
manufacture, distribute, dispense, possess or use any narcotic drug, hallucinogenic drug,
amphetamine, barbiturate, marijuana, alcohol or any other controlled substance, as defined in
State and Federal law, in the workplace.
“Workplace” is the site for the performance of any work done in connection with the District.
The workplace includes any District building, property, vehicles or Board-approved vehicle used
to transport students to and from school or school activities (at other sites off District property) or
any school-sponsored or District activity, event or function, such as a field trip or athletic event,
in which students are under the jurisdiction of District authorities.
As a condition of employment, each employee shall notify his/her supervisor, in writing, of
his/her conviction of any criminal drug statute for a violation occurring in the workplace as
defined above, not later than five days after such conviction.
Employees are given a copy of the Drug-Free Workplace policy and are notified that compliance
with the Drug-Free Workplace policy is mandatory. Employees who violate the policy shall be
subject to disciplinary proceedings in accordance with prescribed administrative regulations,
local, State and Federal law and/or the negotiated agreement, up to and including termination.
Any employee in violation of this policy may be required to participate in a drug-abuse assistance
or rehabilitation program, at the employee’s expense, approved by the Board.
The District may provide the opportunity for employees to participate in a drug-free awareness
program to inform them of requirements, services and penalties.
[Adoption date: May 10, 2010]
LEGAL REFS.: Drug-Free Workplace Act of 1988; 41 USC 701 et seq.;
20 USC 3474, 1221e-3(a)(1)
Drug-Free Campus and Schools Act; 20 USC 3224(a)
ORC 4123.01 et seq.; 4123.35; 4123.54
1 of 2
Pickerington Local School District, Pickerington, Ohio
File: KGC
INITIAL__________
TOBACCO USE ON DISTRICT PROPERTY
Citizens
The Board prohibits the smoking or use of tobacco in any form, including but not limited to
cigarettes, e-cigarettes, cigars, clove cigarettes, pipes, chewing tobacco, snuff and other forms of
tobacco, by any citizen within any school building, within any school-owned vehicles, including
buses, and within any athletic stands at any District-sponsored event.
Citizens who are observed smoking or using other tobacco products within any school building,
any school-owned vehicle, or athletic stand shall be asked to refrain. Violations shall be referred
to the building principal or other District supervisory personnel responsible for the activity or
program during which the violation occurred. The administrator or supervisor shall make every
reasonable attempt to gain compliance with the policy. Repeated violations by an individual
may result in a recommendation to the Superintendent to prohibit an individual from entering
District buildings, riding in school-owned vehicles, or attending school events for a specific
period of time.
Enforcement
The success of this policy will depend upon the thoughtfulness, consideration and cooperation of
tobacco users and non-tobacco users. All individuals on school premises and in school vehicles
share in the responsibility for adhering to and enforcing this policy. Any individual who
observes a violation on school property may report the violation to the appropriate school
official.
[Adoption date: August 21, 1996]
[Re-adoption date: May 10, 2010]
[Revision date: March 10, 2014]
LEGAL REFS.: The Elementary and Secondary Education Act; 20 USC 1221 et seq.
ORC 3313.20; 3313.751
3794.01; 3794.02; 3794.03(F); 3794.04; 3794.06
CROSS REFS.: GBK, Tobacco Use on School Premises by Staff Members
JFCG, Tobacco Use by Students
KGB, Public Conduct on District Property
Pickerington Local School District, Pickerington, Ohio
File: GBP
CROSS REFS.: EB, Safety Program
EEACD, Drug Testing for District Personnel Required to Hold a
Commercial Driver’s License
GBCB, Staff Conduct
GBE, Staff Health and Safety
GBQ, Criminal Records Check
Staff Handbooks
CONTRACT REF.: Teachers’ Master Agreement
2 of 2
Pickerington Local School District, Pickerington, Ohio
Annual 403(b) Plan Eligibility Notice
Pickerington Local Schools offers our eligible employees the opportunity to save for
retirement by participating in the Pickerington Local Schools 403(b) Plan (the “403(b)
plan”). You can participate in this plan by making pre-tax contributions and (if permitted
by the 403(b) plan) Roth 403(b) after-tax contributions. You are eligible to participate in
this plan, whether or not you are actively contributing to it.
Not yet contributing to the 403(b) plan?
To start your contributions to the 403(b) plan, complete and return a salary reduction
agreement to Pickerington Local Schools Treasurer’s Office Payroll Department.
The agreement shall remain in full force until amended or terminated by written
notice from the employee to Pickerington Local Schools. Not more than one
amendment may be made per calendar quarter, although the agreement may be
terminated at any time. Please note that in addition to completing and returning a
salary reduction agreement, you must also establish an account with the appropriate
investment provider(s) that you have selected on the salary reduction agreement and you
may also need to provide any additional information that may be required to enroll you in
the 403(b) plan.
Already contributing to the 403(b) plan? Great News! You have an opportunity to
increase your contributions to the 403(b) Plan.
If you are already currently contributing to the 403(b) plan, you may be able to increase
your pre-tax contributions. To change your contributions, complete and return a salary
reduction agreement to Pickerington Local Schools Treasurer’s Office Payroll
Department. The agreement shall remain in full force until amended or terminated
by written notice from the employee to Pickerington Local Schools. Not more than
one amendment may be made per calendar quarter, although the agreement may be
terminated at any time. Of course, you can keep your contributions at their current
level. In the alternative, if your current financial situation means that you need to lower
your saving for retirement, you can change your contribution rate by completing and
returning a salary reduction agreement as described above.
How much can I contribute?
In general, you may contribute up to $18,000 in 2016. This amount may be adjusted
annually. Also, if you are at least 50 years old and/or you have completed at least 15
years of service, you may also be able to make additional catch-up contributions. Each
catch-up has its own limits.
This Notice is not intended as tax or legal advice. Neither your employer nor the
investment providers offering retirement savings products under the plan can provide you
with tax or legal advice. Employees are encouraged to contact their financial
representative or tax professional with any questions
Pickerington Local School District
457 & 403(b) Vendor Listing
Ohio Deferred Comp Listing
October 1, 2015
457 Vendors
Ohio Deferred Comp, Jason Brown (1-740-701-6994)
[email protected]
ING, Dale Van Valkenburg (614-431-5052)
[email protected]
403b Vendors
American Fidelity (1-800-662-1106)
www.americanfidelity.com
Ameriprise (1-800-297-7378)
www.ameriprise.com
Aspire Financial Services (1-866-634-5873)
www.aspirefinserv.com
AXA Equitable Life Insurance (1-800-487-6669)
www.axa-equitable.com
First Investors 403b (614-487-0182)
www.firstinvestors.com
Great American Life Insurance (1-888-497-8556)
www.gafri.com
Horace Mann (614-863-5900)
www.horacemann.com
ING Life Insurance & Annuity/Relia Star (1-800-262-3862/1-877-884-5050)
www.ing.us
Life insurance of the Southwest (1-800-732-8939)
www.nationallife.com
Lighthouse Agency (1-800-291-9450)
www.lighthouseagency.com
Lincoln Life & Annuity Company/Financial (1-800-893-7168)
www.lfg.com
MetLife (1-877-474-0019)
www.metlife.com
Reserve Financial (1-800-521-3132)
www.resfin.com
Security Benefit (1-740-549-0804)
www.securitybenefit.com
VALIC (1-800-448-2542)
www.valic.com
Pickerington’s 3 for 3 Program
Support Organization Payroll Deduction Program
Take this opportunity to support three organizations that generously support the Pickerington Local
School District and the greater Pickerington community every day.
The Pickerington Food Pantry, the Pickerington Education Foundation, and Vote for Pick Kids are three
support organizations in need of your help. Each is in need of additional support and funding to keep its
mission alive. Making a gift through payroll deductions is an easy, simple, automated way to annually gift
to these Pickerington organizations.
Choose Your Impact
In partnership with the Pickerington Local School District, you now have the opportunity to give to the
Pickerington Food Pantry, the Pickerington Education Foundation, and Vote for Pick Kids through payroll
deduction in a Three for Three Program.
Customize Your Giving
In the Three for Three Program, you may choose to give to any organization, any amount, at any time!
Simply complete the form below and return to the payroll department. The charitable contributions to the
Pickerington Food Pantry and the Pickerington Education Foundation are tax deductible. Donations made
to Vote for Pick Kids Committee is not tax deductible.
3 for 3 Deduction Authorization Form
Employee Name: __________________________________
Last 4 digits of SS #: ______
Home Address: ____________________________________________________________________
Note: PLEASE FILL IN BOTH THE ANNUAL AMOUNT AND THE PER-PAY AMOUNT FOR EACH DEDUCTION.
ANNUAL AMOUNT
PER-PAY AMOUNT
Pickerington Food Pantry
________
________
Pickerington Education Foundation
________
________
Vote for Pick Kids Committee
________
________
I hereby authorize my employer to deduct the designated amount(s) from my pay.
Signature: ________________________________________
Date: ________________________
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