Productivity Enhancement Program
- Enrollment Form for 2004
Family coverage (Check One)
By signing this document,
I elect to participate in the 2004 portion of the Productivity Enhancement
Program (PEP) and agree to the provisions contained in the Productivity Enhancement
Program Description (hereafter Program Description) that is available in my campus
personnel office and on the internet at http://www/brockport.edu/~shra/pep.htm.
I understand that I must meet the eligibility criteria elaborated in the Program
Description in order to participate. I
understand that full-time employees will surrender 0.75 day (i.e., 5.75 or
6 hours for 37.5 and 40 hour workweeks, respectively) of vacation and/or personal
leave as a result of participation (prorated for eligible part-time and hourly
employees) and that ALL of these leave credits will be deducted from my leave
balances at the time my enrollment is processed. Furthermore, I understand
that no portion of this leave will be returned to me under any circumstances.
I wish to apportion this leave forfeiture as follows:
Hours of Vacation Leave
Hours of Personal
for forfeiting this sick leave I will receive a health insurance contribution
credit (hereinafter "credit") of up to $100 to be applied against the
employee share cost of NYSHIP health insurance premiums paid between September
30, 2004 and December 31, 2004. Pursuant to the program description, the amount
of this credit will be established at the time of enrollment and will be adjusted
only upon movement between individual and family coverage. I will not receive
any amount of health insurance premium credit that exceeds the cost of the employee
share of my NYSHIP health insurance premium paid during that period.
I understand that my participation in this program automatically ends on 12/31/
2004 and that I will be required to submit a new enrollment form if I wish to
participate during 2005.
I understand that in order to participate this completed election form must
be filed with my campus personnel office by the close of business on August 27,2004.
Personnel Office Only:
Employee's payroll/employment percentage:
(Enter percent, e.g. 100%, 25%)
Hours of leave deducted from employee's balance:
Verification of eligibility.
I certify that this applicant meets the eligibility criteria necessary for participation
in this program.
For Health Benefits Administrators
Biweekly Health Insurance Contribution Credit:
Copy 1- Health Benefits Administrator
Copy 2- Personnel Office/Attendance Records