Please submit this form and any additional enrollment forms to the Department of Human Resources and Communications when completed within 30 days of hire.
If you wish to contribute to a Dependent Care Flexible Spending Account this school year, please complete this section. Contribution elections do not carry over year-to-year, so if you wish to contribute next year, you will need to complete a new election form.
Authorization & Certification
I authorize Wauwatosa School District to enroll myself and my dependents (if applicable) in the benefit plans indicated above.
I certify that the facts on this form and in Appendix A are true, correct and complete without misrepresentation of any kind. I understand that if any of the information on this document is discovered to be incorrect, false or misleading or if there are any misrepresentations or omissions of any kind, I may be subject to discipline, up to and including termination and/or legal action.
This Electronic Form may be executed by electronically transmitted signatures, (either Penned Bitmapped Signature or Typed Name), and such signatures shall be deemed to be as valid as an original signature whether or not confirmed by delivering the original signatures in person, by courier or by mail.
ATTENTION: Only complete Appendix A if you have selected Family Coverage for any of the plans offered.
If you have elected Employee-Only Coverage for all plans offered, you may scroll to the bottom of the form and submit.
Please Note: The Affordable Care Act Regulations require all insurers and self-insured employer groups to report to the IRS the social security numbers (SSN) for each individual (employee and dependents) for whom the group provides minimal essential coverage primarily to support IRS’ enforcement of the individual mandate.