Productivity Enhancement Program - Enrollment Form for 2004

Name: SSN:
Health Insurance Option:


Individual or 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 Leave
In exchange 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.
Signature ______________________________ Date
For Agency Personnel Office Only:
Employee's payroll/employment percentage: (Enter percent, e.g. 100%, 25%)

Hours of leave deducted from employee's balance:
Vacation: Personal: Date:
Verification of eligibility. I certify that this applicant meets the eligibility criteria necessary for participation in this program.
Name: Title:
Signature: ______________________________ Date:
For Health Benefits Administrators Only:
Date Processed:
Biweekly Health Insurance Contribution Credit:
Name: Title:
Signature: ______________________________ Date:
Copy 1- Health Benefits Administrator
Copy 2- Personnel Office/Attendance Records