SSL Certificate
Superintendent and students
Home /
<<  Departments / Human Resources / Affordable Care Act Insurance Online Form 2016

Affordable Care Act Insurance Online Form 2016

The Patient Protection and Affordable Care Act mandates went into effect on January 1, 2015. The new law requires all applicable large employers, including Quaker Valley School District (QVSD) to offer health insurance coverage to all full time employees, those who work an average of 30 or more hours a week, and their dependents. You may also purchase health insurance through the Marketplace at:

An enrollment period will be held from May 1, 2016 - June 1, 2016. During this period, you will be able to select coverage options at full cost to you. Coverage will go into effect July 1, 2016. You may decline to enroll in the health insurance offered for any reason; you are not required to accept this offer of coverage.

You must complete and submit this form for election of either options. Failure to complete and return this form by June 1, 2016 will result in the closure of the open enrollment period and therefore no changes can be made without a Qualifying Life Event.

Enter an email address or phone number to contact you​​

I acknowledge that I have received an offer of Health Insurance coverage for myself and my dependent(s) by Quaker Valley School District beginning July 1, 2016.

I understand that I cannot change or revoke my election unless a Qualifying Life Event occurs for the applicable benefit. Completed enrollment forms and documentation of a Qualifying Event will be required within 31 days of the event. Examples of Qualifying Life events include Marriage, Divorce, Birth/Adoption of a child, and Loss of Coverage from another Health Care Provider.

Please indicate whether you wish to enroll yourself and your dependents or decline insurance coverage for yourself and your dependents. You will need to complete the appropriate enrollment forms and supply the required supporting documentation to enroll.

choose one​​​
Type your name as a signature​​​

Quaker Valley School District
100 Leetsdale Industrial Drive
Suite B
Leetsdale, PA 15056 map

Phone: 412-749-3600
Fax: 412-749-3601

Directions to District Office
From the Sewickley Bridge (Route 65 & Broad Street in Sewickley), proceed 2.7 miles north on Route 65. At the Leetsdale Industrial Park sign, take the ramp access on the right. Make a left to cross over Route 65 and follow the ramp to the stop sign. At the stop sign, go straight, then make the next right onto Leetsdale Industrial Drive. Go to the third complex entrance on the right. The sign is marked "QVSD Offices." District Office is located in Suite B.

Quaker Valley School District
100 Leetsdale Industrial Drive - Suite B, Leetsdale, PA 15056 | 412-749-3600
powered by finalsite