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EMPLOYER NAME: KITT1TA5 COUNTY <br />EMPLOYEE CUNT <br />Average number of W-2 employees: 394/31 <br />Employees eligible for WCIF benefits: 293/31 <br />Employees enrolled in WCIF medical benefits: 199/0 <br />ELIGIBILITY <br />A current census must accompany each new class designation. For additional classes, attach document. <br />Class Name: Class Code (to appear on bill): # Plan Participants: Census Attached:..OR .. <br />Line 31 ❑ Yes ® No <br />Eligibility: 20 Minimum Hours per week - OR - Hours per month <br />❑ Other: <br />Effective Date: ® The same as WCIF <br />❑ Other: <br />Employer Contribution: Employee: $ or %: 90% <br />❑ 30 day waiting period ❑ 60 day waiting period ❑ Fire District <br />Class Mame. <br />Eligibility: <br />Dependents: $ or %: Composite: $ or %: <br />Class Code: (to appear on bill) # Plan Participants: Census Attached: <br />❑ Yes ❑ No <br />Minimum Hours per week - OR - <br />❑ Other: <br />Effective Date: ❑ The same as WCIF <br />❑ Other: <br />_mployer Contribution: Employee: $ or W <br />❑ 30 day waiting period <br />Hours per month <br />❑ 60 day waiting period <br />Dependents: $ or % <br />❑ Fire District <br />Composite: $ or W <br />Will the group process enrollment via the WCIF/Benefit Solutions, Inc. (BSI) Web Enrollment System? ® Yes ❑ No <br />If YES, for access to the online enrollment system and billing services, indicate the individual(s) authorized for WCIF Web <br />Enrollment System updates. An email invitation will be sent out to the designated individual(s) to register for Web Enrollment <br />System functionality. <br />dame & Title: Email: (Mandatory) Phone: <br />Lisa Young, HR Director/Risk Manager lisa.young@co.kittitas.wa.us 509-962-7084 <br />dame & Title: Email: (Mandatory) Phone: <br />Chelsea Lierly, HR Representative I chelsea.lierly@co.kittitas.wa.us 509-962-7082 <br />We: If access for an additional user is desired, please contact BSI for request form. <br />Does your organization offer non-WCIF medical plans to employees? ® Yes (if YES, list carrier(s) below) <br />Other Medical Carrier 1: Washington Teamsters Welfare Trust/NW Administrators (Line and Probation Only) <br />Other Medical Carrier 2: <br />❑ No <br />2017LMGMA2 Page 3 of 9 (092116JM) <br />