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Benefit Forms

Benefit Forms

During Open Enrollment (typically May to mid-June) you are eligible to make changes to your benefits without a qualifying event. Benefit changes made during Open Enrollment become effective July 1st. Benefit forms marked with an * can only be submitted as a result of a qualifying event or during open enrollment.

Section 125 Worksheet*

This worksheet can be used to help you decide how much to set aside in a flexible spending account


Section 125 (Flexible Benefit) Plan*

A section 125 plan allows you to set aside money, through payroll deduction, on a pre-tax basis to cover health expenses not covered by your health insurance or for dependent care expenses. This is an annual election amount, so even if you currently participate in this program you must complete a new form. Section 125 Plan Savings Calculators, such as are available on the internet to calculate the tax savings of utilizing a Section 125 Plan. A Section 125 Worksheet is attached to help you decide how much you might want to set aside.


Enrollment Form

Reimbursement Request Form


403(b) Tax Deferred Retirement Plan

A 403(b) plan is a tax-sheltered annuity (TSA) plan. These plans are available to employees of public school, certain tax-exempt organizations and certain ministers. Some benefits of a 403(b) plan are: (1) you do not pay income tax on allowable contributions until you being making withdrawals from the plan, usually after you retire and (2) earnings and gains on amounts invested are not taxed until you withdraw them.


CPI Qualified Plan Consultants, Inc. is the administrator of the Shaker Regional 403(b) Plan, Plan #106070. You can enroll in a 403(b) plan at any time, with a participating vendor. Please contact the SAU office at 267-9223 ext. 303 or for additional information. You may also visit the CPI Qualified Plan Consultant website at


Health & Dental Insurance*

Shaker Regional School District offers health and dental insurance to our employees who are contracted to work 30 hours or more per week. It is the responsibility of the employee to notify the SAU Office within 31 days of a status change. Status changes include: birth, adoption, marriage, divorce, legal separation, death, or a child reaching the age of 26.


Health Insurance Enrollment/Change Form

Dental Insurance Enrollment/Change Form


Short-Term Disability (Only available when you are hired or during Open Enrollment)

This program provides income replacement if you are disabled due to injury or sickness and are out of work without pay. The insurance is provided by Dearborn National. You must work a minimum of 30 hours per week to participate in the program.


Short Term Disability Insurance Enrollment Form

Short Term Disability Rates