JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
BENEFIT DECLARATION - 2024 - 2025
Complete only if you have current benefits with Baldwin-Whitehall School District.
Questions: Contact Georgann Helman at 412-884-6300, Ext. 7461.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
FIRST NAME
*
Your answer
LAST NAME
*
Your answer
PHONE NUMBER
*
Your answer
EMAIL ADDRESS
*
Your answer
EMPLOYEE TYPE
*
Act 93/Superintendent/Deputy Superintendent/Dir. of Finance & Operations/Confidential Admin. Assistant
Bus Driver/Bus Attendant/Mechanic/Cleaner
Custodian/Maintenance
Extracurricular/Supplemental
Food Service Worker
Health Services Nurse
Noontime Aide/Breakfast Monitor
Paraprofessional
Secretary
Student Monitor
Teacher (Includes BWEA Professional Employee)
Technician/Level I/Level II
Other:
I HAVE REVIEWED MY PERSONAL BENEFIT CONFIRMATION STATEMENT FROM APRIL 2024. EFFECTIVE JULY 1, 2024, I AGREE WITH THE FOLLOWING:
*
1. I am satisfied with my current benefits and I do not want to make any changes.
2. I want to make changes to my current benefits and I will complete the ACSHIC Enrollment Form and submit all documentation by May 31, 2024 to Georgann Helman at Administration.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Baldwin-Whitehall School District.
Report Abuse
Forms
