Name of Grievant Building Assignment Date Filed. The date(s) on which the alleged violation, misinterpretation or misapplication of a provision(s) of the Agreement occurred: The provision(s) of the Agreement which has been violated, misinterpreted or misapplied: The facts on which the alleged grievance is based (Attach a separate sheet to this Grievance Faun if a complete statement of the facts requires more space than is provided on this form): APPENDIX B The remedy sought: Signature of Grievant Date I hereby acknowledge that this grievance was filed with me on the date set forth below: Signature of Principal or Immediate Supervisor Date Disposition of Principal or Immediate Supervisor Signature Date APPENDIX B STEP 3 I hereby notify the Superintendent that this grievance is being appealed to STEP 3. The reason for the appeal is as follows: Signature of Grievant Date I hereby acknowledge that this grievance was filed with me on the date set forth below: Signature of Superintendent Date Disposition of Superintendent: APPENDIX B STEP 4 I hereby notify the Superintendent that this grievance is being appealed to STEP 4. The reason for the appeal is as follows: Signature of Grievant Date I hereby acknowledge that this grievance was filed with me on the date set forth below: Signature of Superintendent Date Disposition of STEP 4: 57
Name of Grievant Building Assignment Date Filed. The date(s) on which the alleged violation, misinterpretation or misapplication of a provision(s) of the Agreement occurred: The provision(s) of the Agreement which has been violated, misinterpreted or misapplied: The facts on which the alleged grievance is based (Attach a separate sheet to this Grievance Form if a complete statement of the facts requires more space than is provided on this form): The remedy sought: Signature of Grievant Date I hereby acknowledge that this grievance was filed with me on the date set forth below: Signature of Principal or Immediate Supervisor Date Disposition of Principal or Immediate Supervisor Signature Date Signature of Grievant Date I hereby acknowledge that this grievance was filed with me on the date set forth below: Signature of Superintendent Date Disposition of Superintendent: Signature Date Signature of Grievant Date I hereby acknowledge that this grievance was filed with me on the date set forth below: Signature of Superintendent Date Disposition of STEP 4: Signature Date HESE WELLNESS PLAN MEDICAL AND RX Huron-Erie School Employee Insurance Association MEDICAL Wellness Plan Benefits Network Non-Network Benefit Period January 1st through December 31st Dependent Age Limit 26 Removal upon End of Month Blood Pint Deductible 0 pints Overall Annual Benefit Period Maximum Unlimited Wellness Plan Deductible – Single/Family1 $500 / $1,000 $500 / $1,000 High Deductible Health Plan – Single/Family1 $750 / $1,500 $750 / $1,500 Requirements for Wellness Plan (Deductible change occurs on calendar years basis) Complete Screening and/or Physician form and Health Assessment – November 1st. Complete Screening and/or Physician form and Health Assessment – November 1st. Coinsurance 90% 70% Coinsurance Out-of-Pocket Maximum (Excluding Deductible) – Single/Family $1,000 / $2,000 (Wellness) $750 / $1,500 (HDHP) $2,500 / $5,000 (Wellness) $2,250 / $4,500 (HDHP) Coinsurance Out-of-Pocket Maximum (Including Deductible) – Single/Family $1,500 / $3,000 (Wellness) $1,500 / $3,000 (HDHP) $3,000 / $6,000 (Wellness) $3,000 / $6,000 (HDHP) Physician Office Services Office Visit (Illness/Injury)2 $25 copay, then 100% $25 copay, then 70% Specialist Office Visit2 $40 copay, then 100% $40 copay, then 70% Urgent Care Office Visit2 $40 copay, then 100% $40 copay, then 70% Preventive Services Preventive Services, in accordance with federal law6 100% 70% after deductible Routine Physical Exams2 100% $25 copay, then 70% Well Child Care Services includin...
