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Odessa R-VII School District 2017
Odessa R-VII
2017Benefits Enrollment Worksheet
In order to expedite your enrollment, it is recommended that you complete this worksheet. Any missing information could slow
down your enrollment experience.
Legal Name
SSN
Relationship
Gender Date of
Birth
Medical
Yes / No
Dental
Yes/No
Vision
Yes/No
MEDICAL – HUMANA
QHDHP
BASE PPO
BUY-UP PPO
Retiree Only
$497.21
$588.71
$643.74
Retiree + Spouse
$994.41
$1,177.42
$1,287.49
Retiree + Child(ren)
$1,019.27
$1,206.86
$1,319.68
Family
$1,402.12
$1,660.17
$1,815.36
Would you like to receive future benefits and enrollment communication electronically?
Yes. Please provide your email address: ______________________________
No
VISION – SUPERIOR
Employee Only
$8.93
Employee + Spouse
$15.17
Family
$25.19
Waive
DENTAL – DELTA DENTAL OF MO:
Retiree Only
$35.29
$44.03
Retiree + Spouse
$69.11
$86.24
Retiree + Child(ren)
$99.90
$124.52
Family
$133.57
$166.68
Waive