аЯрЁБс>ўџ DFўџџџCџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅС љП]bjbjрр *:‚j‚jOџџџџџџlœœœœœœœАŒŒŒŒ$А4А.№ФД Д Д Д Д žR dЖ 4UWWWWWW$< \Œ{-œъ Д Д ъ ъ {d œœД Д Ј*d d d ъ FœД œД Ud ъ Ud оd B:љ,œœ9Д ф €вa1"ЦАмŒ0 F% 9в</ шv юш9d ААœœœœйAFSCME and State of Michigan Health Insurance Assistance Application Please send a copy of your insurance payment coupon and the check you are sending to pay the bill along with this completed application form. Your AFSCME Union has negotiated the right to reimburse a portion of your health insurance premiums from the Employee Education and Resource Fund. *One (1) month of your health insurance will be reimbursed from this Fund (if you are not covered by any other health insurance). This includes insurance coverage from your spouse, insurance from other employment, medicare, Medicaid, SSI, or other types of insurance. You must complete the lower portion of this form and attach both a copy of the health insurance billing showing the time period billed, as well as a copy of your proof of payment. Payment from the Fund will be for health insurance only, and will not include vision, dental, life or long term disability. REQUEST FOR HEALTH INSURANCE REIMBURSEMENT EMPLOYEE NAME  FORMTEXT       AGENCY FORMTEXT       EMPLOYEE ADDRESS  FORMTEXT       EMPLOYEE I.D. #  FORMTEXT       CLASSIFICATION  FORMTEXT       LOCAL UNION NO  FORMTEXT       PHONE  FORMTEXT       IF RECALLED, GIVE DATE  FORMTEXT       CURRENT COVERAGE: (Check One)  FORMCHECKBOX  EMPLOYEE ONLY  FORMCHECKBOX  EMPLOYEE & SPOUSE  FORMCHECKBOX  EMPLOYEE & CHILD(REN)  FORMCHECKBOX  EMPLOYEE, SPOUSE & CHILD(REN) By my signature, I affirm that NO other health insurance coverage is provided for myself, or those indicated above. EMPLOYEE SIGNATURE__________________________________________DATE__________________________ MAIL TO: MICHIGAN AFSCME COUNCIL 25, 3625 DOUGLAS AVE., KALAMAZOO MI 49004-3403, ATTN: HEALTH INSURANCE REIMBURSEMENT SD/cjd:iuoe547aflcio *A maximum of three (3) months reimbursement may be approved during the period of layoff. Institutional Unit Criteria for Reimbursement from the Employee Education and Resource Fund Reimbursement is to enable non-probationary Bargaining Unit employees to obtain the education necessary for state classified jobs that have post high school educational requirements up to and including a master’s degree. Application for reimbursement must be submitted within six (6) months after completing a course. Classes that began prior to the employee’s hire date are not eligible for reimbursement. An initial probationary employee who enrolls in a course after starting work for the State must wait to submit the application for reimbursement until s/he achieves status. Applications must be submitted within six (6) months after achieving status. Employees must attend an accredited college or university (including correspondence or distance learning course(s) from an accredited school that would lead to a degree) or a state-licensed trade school. A list of non–accredited colleges and universities is available at: http://www.michigan.gov/documents/Non-accreditedSchools_78080_7.pdf. Tuition/registration for a course will only be reimbursed once. Reimbursements will not be made for a degree of the same level as one already reimbursed through this fund. Employees must fully complete, sign, and mail to AFSCME’s Kalamazoo office an Application for Tuition Reimbursement form, along with proof of payment for the course(s), proof of satisfactory completion of the course(s) (i.e., course credit), and a copy of the institution’s per credit-hour rate. Employees must be registered in the vendor file. It is the employee’s responsibility to register and update any change in the file. Tuition Reimbursement is limited to: Actual tuition costs and registration fees, up to $2,500 per person per fiscal year. For distance learning courses in which credit is earned only by exam, the cost of the exam will be reimbursed, but there is no reimbursement for tuition. Other fees, such as graduation, late payment, parking, and technical fees, books, and other items are not tuition and will not be considered for reimbursement. Any grants or scholarships received will be subtracted from the employee’s total billed education costs, excluding any lodging/meal/transportation costs, for the term/semester. The remaining balance will be considered for reimbursement eligibility. Additionally, employees in departments that provide tuition reimbursement must apply to their department and include a copy of the response with their application to this fund. Any reimbursement received from a department or other fund for tuition and registration/enrollment fees will be deducted prior to determining eligibility for reimbursement from this fund. In no case shall reimbursement exceed the total billed cost. Employees whose applications are approved will be expected to continue to work for the State for a period of time equivalent to the time they attended school under this program (e.g., equivalent to one or more terms or semesters). The fund shall be utilized to reimburse laid-off status employees for their continuation of State of Michigan group health insurance payments. Reimbursement shall be limited to three months, except in extraordinary circumstances as approved by the committee. Applicants need to submit copies of their payment coupons and payment checks. 12.Payment will be on a first-come, first-served basis, with priority given first to reimburse employees for health insurance. Secondly, educational reimbursements will be made generally on a quarterly schedule. In the event of insufficient funds, payments will be based on seniority. 13.Legitimate charges to the fund include: postage costs for correspondence to applicants; supplies and equipment not to exceed a total of $100.00 without further committee approval; and the hourly fee for one (1) temporary part-time assistant provided and supervised by Council 25 for reasonable and necessary support services for the fund. The Office of the State Employer will receive half as much as Council 25 to offset some of the administrative costs. 14.The Office of the State Employer shall maintain on file for auditing purposes the appropriate documentation verifying disbursements, which they have approved. 15.The committee established under the collective bargaining agreement shall meet at the request of either party to address any changes in the utilization of this fund. 16.Tuition reimbursement applications are available online at www.michigan.gov/ose and www.miafscme.org. Send applications to: Michigan afscme Council 25, 3625 Douglas Ave., Kalamazoo, MI 49004-3403 If you have any questions, you may contact Stacie Dineen at (269) 343-0348, toll-free (866) 405-6800 or by email at: kzoo@miafsme.org. Criteria approved July 20, 2005 GежДЯвъOdЋжзхц№ё  246@Bjl€‚„ŽДЖЪЬЮикќў   " D F Z §їяъїтїъмъїъгъЧгИгъгъЌгИгъгъ гИгъгъ”гИгъгъˆгИгъгъjаOJQJUj\OJQJUjшOJQJUjtOJQJUjOJQJUmHnHujOJQJUjOJQJU >*OJQJ5>*OJQJOJQJ56OJQJ 5OJQJCJ3EFGежwxЉЊЋжзDF’”моl n ј њ  §јјјіёёёёфётјйёёёёёйёаёё$ Цxa$$ ЦАa$ $&d PЦџ a$$a$$a$]ўZ \ ^ h j z |  ’ ” ž   Ђ а в ц ш ъ є і ј њ    + , - > ? 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