аЯрЁБс>ўџ ;=ўџџџ:џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅСY  П“bjbjѓWѓW 12‘=‘=F џџџџџџ]иииииииьььььDьк ЖX”ььььь~jLЖ($&&&;ao} $ є„ ЖЁ 9иоььооЁ ^ииььX^^^о иьиь$ььиииио$^Ц^$ии$ьD[hЎ[Сььшv$ SICK LEAVE EXCHANGE PROGRAM - ELECTION FORM Name FORMTEXT      SS# FORMTEXT      Health Insurance Option FORMDROPDOWN  FORMTEXT      Individual  FORMCHECKBOX  or Family  FORMCHECKBOX  Coverage (Check One)By signing this document, I elect to participate in the Sick Leave Exchange Program and agree to the provisions contained in the Sick Leave Exchange Program Description (hereafter Program Description) that is available in my campus personnel office and on the internet at: http://www/brockport.edu/~hr/slep.htm . I understand that I must meet the eligibility criteria elaborated in the Program Description in order to participate. I understand that, during the period of my obligation between January 1, 2002 and December 31, 2002, I will earn less sick leave than I normally would as a non-participant. In exchange for forfeiting this sick leave, I will receive a credit to be applied against the cost of NYSHIP health insurance premiums. This credit can be used ONLY for the purpose of reducing the employee share of my NYSHIP health insurance premium. I will not receive any amount of health insurance premium credit which exceeds the cost of the employee share of my NYSHIP health insurance premium paid between January 1 and December 31, 2002. I understand that the reduction in my sick leave accrual rate will be assessed beginning with the month of January 2002 until such time that I would have normally accrued the amount of leave that I am required to forfeit under the program. I have read the program description and understand the conditions under which I will lose eligibility to participate. I understand that if I should fail to meet eligibility criteria at any point during the calendar year of participation the unused portion of my health insurance premium credit will no longer be available and my sick leave balance will be adjusted in accordance with the guidelines provided in the Program Description. Furthermore, I understand that any loss of eligibility during the calendar year of participation will disqualify me from further participation in the program during that calendar year. I understand that my participation in this program automatically ends on December 31, 2002 and that participation in the Sick Leave Exchange Program in subsequent years, requires that I submit a new enrollment form during the election period applicable to the calendar year in question. I understand that this is a pilot program which will expire on December 31, 2003. 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 November 30, 2001. SignatureDate FORMTEXT       Send Completed Form to: FORMTEXT       FORMTEXT      NameDepartment------------------------------------------------------------------------------------------------------------------------------------------- For Agency Personnel Office Only: Verification of eligibility. I certify that this applicant meets the eligibility criteria necessary for participation in this program. 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