PEP 2008

Productivity Enhancement Program for 2008 � Enrollment Form

Name_____________________________________________ SS#__________________

Health Insurance Plan______________________________________________________

Individual [ ] or Family Coverage [ ] (CHECK ONE)

By signing this document, I elect to participate in the 2008 portion of the Productivity Enhancement Program (PEP)
and agree to the provisions contained in the Productivity Enhancement Program Description (hereafter Program Description)
that is available in my campus Human Resources Office. I understand that I must meet the eligibility criteria explained in the
Program Description in order to participate.

I understand that full-time employees will surrender 2 days of Annual leave as a result of participation in the program
and that part-time employees will surrender 1 day as a result of participation. Furthermore, I understand that ALL of these
leave credits will be deducted from my leave balances at the time my enrollment is processed. Furthermore, I understand that
no portion of this leave will be returned to me under any circumstances.

In exchange for forfeiting this accrued leave I will receive a health insurance contribution credit (hereafter �credit�) to
be applied against the employee share cost of NYSHIP health insurance premiums paid in the 2008 NYSHIP plan year. The
maximum possible amount of this credit for 2008 is $300 for full-time employees and $150 for part-time employees. Pursuant
to the program description, the amount of this credit will be established at the time of enrollment and will be adjusted only
upon movement between individual and family coverage. I understand that I will not receive any amount of credit that exceeds
the cost of the employee share of my NYSHIP health insurance premiums paid during that period.

I understand that this enrollment form only applies to the 2008 NYSHIP plan year.
I understand that in order to participate, this completed election form must be filed with my campus Human Resources
Office by the close of business on May 24, 2008.

Signature________________________________________________ Date____________

PERSONAL PRIVACY PROTECTION LAW NOTIFICATION
This information is being requested pursuant to New York State Civil Service Law section 161-a for the principal purpose of determining eligibility for the
Productivity Enhancement Program for 2008. This information will be used in accordance with Public Officers Law section 96(1). Failure to provide this
information may result in a denial of eligibility to participate in the Productivity Enhancement Program for 2008. This information will be maintained by the
employee�s Agency Personnel Office. For further information relating only to the Personal Privacy Protection Law, contact pio@cs.state.ny.us.


For Agency Human Resources Office Only:

Full-time__________ Part-time__________ (check one)

Days of annual leave deducted from employee�s balance: __________ Date__________

Verification of eligibility. I certify that this applicant meets the eligibility criteria necessary for participation in this program.

Name___________________________________ Title___________________________

Signature________________________________ Date___________________________


For Health Benefits Administrators Only:

Date Processed____________________

Biweekly Health Insurance Contribution Credit___________________

Name___________________________________ Title___________________________

Signature________________________________ Date___________________________