OSCAR Information
Print this page


Required authorizations

Dean/Vice President/Vice Provost or Designee

This request must be approved at the Dean/Vice President/Vice Provost level.  The Office of the Provost maintains the list of authorized delegated signature authorities.  The individual signing as Dean or Vice President must be named on the OSU Delegated Signature Authority List.

If your Dean/Vice President/Vice Provost requires authorization from another person in his/her unit, have this person sign and date the form in the space just above the Approvals/Signatures section.

The authorized signer on this task will sign this statement, "My signature indicates that the employee(s) named on all pages of the form are not expected to return in the fall in a benefit-eligible position(s).  I understand that insurance coverage for the summer may not be provided and the coverage end date will be determined according to the Affordable Care Act (ACA) and PEBB (Public Employee Benefit Board) rules and regulations.  Rights to self-pay insurance coverage through COBRA will be provided to the employee(s) through the PEBB third party administrator, if applicable."

Terminate Summer Insurance action is required for the following:

Where to send completed form

Employee Benefits / Office of Human Resources
In-person delivery: 236 Kerr Administration Building

Campus & postal mail:
Employee Benefits
Office of Human Resources
Oregon State University
236 Kerr Administration Building
Corvallis, OR 97331-2132

Additional instructions

Summer insurance coverage is provided to academic-year employees in benefits-eligible positions in the spring if they are scheduled to return to work in benefits-eligible positions the following fall term. Summer insurance may also be continued if the employee qualifies under the Affordable Care Act (ACA) and is returning the following fall term regardless of position FTE. Benefits are "triple deducted" in May to pay for summer coverage.

This task notifies OHR Employee Benefits when a benefits-eligible academic-year employee working in the spring will not be returning in a benefits-eligible position in the fall. If you are unsure about the continued employment status of an employee, do not add their name to the list!  If there is any possibility that the employee will be returning in the fall to a benefits-eligible position, the employee should receive summer insurance coverage.

DEADLINE: Employee Benefits must receive your form each year by 5PM May 3.  This ensures that the "triple deduction" for summer coverage is not taken from the May check.  You may send multiple forms as you become aware of employees who will not be returning.  Do not report an employee more than once.

After May 4 but before June 1: if you become aware of additional employees who will not return in the fall, you may continue to report them to Employee Benefits using this form.  Employee Benefits will make a retroactive correction on the June payroll for these employees.

No corrections may be made after June 1 (the employee will receive insurance coverage through September 30.)

Revised 03/13/19
Finish and close this window