Insurance Premiums Online Payment Form

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Name Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Please select your classification

Please select your classification Classified/Confidential Certificated Administrative/Management Board Member
Please find the plan coverage you elected and then select the payment option from the appropriate drop down menu.
Comprehensive Employee Only - $600 annually
Comprehensive Employee + Child(ren) - $900 annually
Comprehensive Employee + Spouse $1,200 annually
Comprehensive Employee + Family - $1,200 annually
Basic Employee + Child(ren) - $300 annually
Basic Employee + Spouse $600 annually
Basic Employee + Family - $600 annually
Other payment amount (only select if you are paying an amount other than one listed in the drop down menu above) $ Dollars . Cents
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