2015-2016

CBJ BI- WEEKLY PREMIUM

FOR HEALTH INSURANCE OF PART- TIME EMPLOYEES or EMPLOYEES ON LWOP

July 1, 2015 – June 30, 2016

Pay Period From: _____________________	To: __________________

Employee Name: _____________________	Dept: ________________

Employee Number: ___________________	Employee Co-pay ______

Hours are calculated on a weekly basis. Employee will not receive credit for overtime hours each week.

Week ONE total paid hours worked:	____________ (Max. 40 hours)

Week TWO total paid hours worked:	____________ (Max. 40 hours)

Total paid hours for this pay period	____________

Credited Amount	X $ 8.60

Total Credited Amount	____________

FOR PAYROLL USE

Bi-weekly premium	$ 687.69	RATE OF PAY	HRS

Less Credited Amount	____________

Employee Co-pay	____________

Employees Pro-rated Premium	____________ ________ = _______

Employee Signature: __________________________	Date: _______________________

Department Approval: _________________________	Date: _______________________

*OPTION to use Personal Leave to cover health insurance costs*

Employee Signature: ____________________

7/27/15 80 HR PSEA worksheet