CAPABILITY OVERVIEW

27 / 27

27 Bonner Springs/Edwardsville USD 204
Bonner Springs/Edwardsville USD 204
2017 Retiree Benefits Enrollment Worksheet
This form must be returned to Stormi Vitt in the District office no later than May 12, 2017.
Legal Name SSN Relationship Gender
Date
of
Birth
Medical
Yes / No
HMO
PCP #
Dental
Yes/No
Vision
Yes/No
.
MEDICAL – BCBS OF KC
QHDHP #1 QHDHP #2 BASE PPO HMO BUY-UP PPO
Retiree Only  $454.10  $399.61  $468.19  $502.89  $553.80
Family  $1,139.75  $1,002.98  $1,173.96  $1,260.96  $1,390.00
Waive 
Would you like to receive future benefits and enrollment communication electronically?
Yes. Please provide your email address: ______________________________
No
DENTAL – DELTA DENTAL OF KS: VISION - SURENCY
Retiree Only  $30.57 Retiree Only  $7.76
Retiree + Spouse  $60.51 Retiree + Spouse  $16.27
Retiree + Child(ren)  $60.80 Retiree + Child(ren)  $13.95
Family  $102.94 Family  $26.10
Waive  Waive 