I ____________________________________PIN #_______________, agree that I have read and understand the 2023 Open Enrollment guidelines and instructions for State Health Benefit Plan and the GaBreeze Flex Benefits offered through Glynn County School System. I verify that I have followed all instructions as stated below. I fully understand that all options and elections must be made during the Open Enrollment Period beginning Monday Oct 16, 2023 @ 12:00am and ending Friday Nov 3, 2023 @ 11:59pm. I fully understand that if I do not follow online or call-in Open Enrollment instructions, my 2024 HEALTH insurance will default to my current 2023 Plan Option with new plan year rates under State Health Benefit Plan beginning January 01, 2024. *** I further understand that I have been offered a health insurance plan under SHBP of Georgia that meets the minimum Affordability Care Act requirements of minimal essential coverage and affordability as defined by law. *** I am aware that it is MY responsibility to verify and make sure spelling of name(s), date(s) of birth, and social security # (s) are correct on myself and any covered dependents, to assure that correct information is sent to the IRS for the 1095C***
I also understand that if I do not go online or call GABREEZE to make any changes, my 2024 flex benefits will default to the 2023 plan year at the new plan year rates, with the exception of the Spending Accounts. I understand that the Flexible Spending Health Care and/or Dependent Care Flexible Spending Account will NOT automatically roll over and I must go online or call GaBreeze to enroll for the SPENDING ACCOUNT options in 2024.
