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</o:shapelayout></xml><![endif]--></head><body lang=EN-US link=blue vlink=purple><div class=WordSection1><p class=MsoNormal align=center style='text-align:center'><b><span style='font-size:18.0pt;font-family:"Arial","sans-serif";color:#00B050'>Out-of-Pocket Cost Sheet<o:p></o:p></span></b></p><p class=MsoNormal align=center style='text-align:center'><span style='font-size:16.0pt;font-family:"Arial","sans-serif";color:#E36C0A'>It’s that time once again!<o:p></o:p></span></p><p class=MsoNormal><span style='font-size:12.0pt;font-family:"Arial","sans-serif"'>OEBB would like to give you the opportunity to provide your educational entity Out-of-Pocket Cost Sheet for the upcoming 2011-12 Plan Year. This will allow your employees to review their costs/contributions online while enrolling in benefits during the 2011-12 open enrollment period from August 15<sup>th</sup> through September 15<sup>th</sup>.<o:p></o:p></span></p><p class=MsoNormal><span style='font-family:"Arial","sans-serif";color:#E36C0A'><o:p> </o:p></span></p><p class=MsoNormal align=center style='text-align:center'><span style='font-size:16.0pt;font-family:"Arial","sans-serif";color:#E36C0A'>OEBB Out-of Pocket Cost Sheet Guidelines<o:p></o:p></span></p><p class=MsoListParagraphCxSpFirst style='text-indent:-.25in;mso-list:l1 level1 lfo1'><![if !supportLists]><span style='font-size:12.0pt;line-height:115%;font-family:Symbol'><span style='mso-list:Ignore'>·<span style='font:7.0pt "Times New Roman"'> </span></span></span><![endif]><span style='font-size:12.0pt;line-height:115%;font-family:"Arial","sans-serif"'>Please submit <u>one document</u> (<i>with all your plan selections</i>) which will represent the Out-of-Pocket Cost Sheet as indicated per educational entity. Remember, this means all your employee/member types will utilize the same document. So, <i>if I am a Licensed-Full-time/OEA employee, I will also see the costs/contributions for Classified-Full-time/OSEA employees for my entity.<o:p></o:p></i></span></p><p class=MsoListParagraphCxSpMiddle style='text-indent:-.25in;mso-list:l1 level1 lfo1'><![if !supportLists]><span style='font-size:12.0pt;line-height:115%;font-family:Symbol'><span style='mso-list:Ignore'>·<span style='font:7.0pt "Times New Roman"'> </span></span></span><![endif]><span style='font-size:12.0pt;line-height:115%;font-family:"Arial","sans-serif"'>Employees from your educational entity will only see the Out-of-Pocket Cost Sheet for their school. So, <i>if I work at the Astoria School District I won’t see the Tillamook School District Out of Pocket Cost Sheet; I will only see the Astoria document.</i><o:p></o:p></span></p><p class=MsoListParagraphCxSpMiddle style='text-indent:-.25in;mso-list:l1 level1 lfo1'><![if !supportLists]><span style='font-size:12.0pt;line-height:115%;font-family:Symbol'><span style='mso-list:Ignore'>·<span style='font:7.0pt "Times New Roman"'> </span></span></span><![endif]><span style='font-size:12.0pt;line-height:115%;font-family:"Arial","sans-serif"'>Please make sure your document is accurate as OEBB will not take responsibility for the accuracy and/or completeness of the Out-of-Pocket Cost Sheet provided.<o:p></o:p></span></p><p class=MsoListParagraphCxSpLast style='text-indent:-.25in;mso-list:l1 level1 lfo1'><![if !supportLists]><span style='font-size:12.0pt;line-height:115%;font-family:Symbol'><span style='mso-list:Ignore'>·<span style='font:7.0pt "Times New Roman"'> </span></span></span><![endif]><span style='font-size:12.0pt;line-height:115%;font-family:"Arial","sans-serif"'>If your educational entity should choose not to submit an Out-of-Pocket Cost Sheet, OEBB will provide a statement directing the employee to contact their educational entity benefits office.<o:p></o:p></span></p><p class=MsoNormal align=center style='text-align:center'><span style='font-size:16.0pt;font-family:"Arial","sans-serif";color:#E36C0A'>How do I submit my Out- of- Pocket Cost Sheet?<o:p></o:p></span></p><p class=MsoListParagraphCxSpFirst align=center style='text-align:center;text-indent:-.25in;mso-list:l0 level1 lfo2'><![if !supportLists]><span style='font-size:12.0pt;line-height:115%;font-family:Symbol'><span style='mso-list:Ignore'>·<span style='font:7.0pt "Times New Roman"'> </span></span></span><![endif]><span style='font-size:12.0pt;line-height:115%;font-family:"Arial","sans-serif"'>OEBB will allow one Word or Excel document per educational entity.<o:p></o:p></span></p><p class=MsoListParagraphCxSpLast align=center style='text-align:center;text-indent:-.25in;mso-list:l0 level1 lfo2'><![if !supportLists]><span style='font-size:12.0pt;line-height:115%;font-family:Symbol'><span style='mso-list:Ignore'>·<span style='font:7.0pt "Times New Roman"'> </span></span></span><![endif]><span style='font-size:12.0pt;line-height:115%;font-family:"Arial","sans-serif"'>We are asking that you send this document to Lynn Pancoast via email no later than July 29<sup>th</sup>. Due to the nature of this document OEBB cannot accept this document via fax, scan or hard copy.<o:p></o:p></span></p><p class=MsoNormal align=center style='text-align:center'><span style='font-family:"Arial","sans-serif"'><a href="mailto:lynn.m.pancoast@state.or.us">lynn.m.pancoast@state.or.us</a><o:p></o:p></span></p><p class=MsoNormal align=center style='text-align:center'><span style='font-family:"Arial","sans-serif"'><o:p> </o:p></span></p><p class=MsoNormal align=center style='text-align:center'><span style='font-size:14.0pt;font-family:"Arial","sans-serif";color:#00B050'>Need OEBB assistance? Call 1 (888) 4MY-OEBB!<o:p></o:p></span></p></div></body></html>