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Employee’s Withholding Allowance Certificate Form W-4
To learn more about W-4 Form Click here
Click here to view the PDF file and the Instructions of W-4 Form. (2019)
To learn more about W-4 Form Click here
Click here to view the PDF file and the Instructions of W-4 Form. (2019)
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If I am applying for coverage for my domestic partner, I represent and warrant that I and my domestic partner: 1) cohabit and reside together in the same residence and have done so for at least six months and intend to do so indefinitely; 2) are engaged in an exclusive and committed relationship and are financially interdependent; 3) are both at least 18 years of age and are each other’s sole domestic partner; 4) are not married or separated from anyone else; 5) have not had another domestic partner within six months of establishing the current domestic partnership; 6) are not related by blood; and 7) are not in this relationship solely for the purpose of obtaining insurance benefits.
If you are entitled to Medicare and Medicare is your primary coverage, you should enroll in and maintain that coverage, because when Medical Mutual is the secondary payer to Medicare Part B, Medical Mutual’s plan will coordinate benefits as if you were covered under Part B, even if you are not. This can result in you being responsible for costs that would have been paid by Medicare. Your broker can assist you with any questions. (If you are entitled to Medicare because you are 65 and over and your employer employs fewer than 20 employees; or if you are entitled to Medicare due to disability and your employer employs fewer than 100 employees, Medicare will be the primary payer, that is, Medicare must pay benefits before the group health plan pays benefits.)
I hereby apply to the carrier(s) offering the coverage indicated on this application. I acknowledge that by enrolling in these products, coverage is provided by the following entities (collectively referred to as “Medical Mutual”): • Medical Mutual of Ohio® (MMO) • Medical Health Insuring Corporation of Ohio® (MHICO) • Consumers Life Insurance Company® (CLIC) for life, accidental death and dismemberment, and disability benefits.
1. I authorize: (1) payroll deduction(s) and remittance of any required contribution for coverage to Medical Mutual and/or any affiliates or divisions of Medical Mutual; (2) release of information, without limitation, from any medical/medically related facility, prior health insurance carrier, the Medical Information Bureau, Inc. (MIB), prescription history database supplier, pharmacy benefit manager, government agency or person to Medical Mutual and/or any affiliates or division of Medical. (a) to evaluate this Application; (b) to adjudicate claims submitted on behalf of me or my dependents; (c) for utilization review programs to monitor health services or quality improvement activities and/or; (d) for credentialing purposes. I authorize Medical Mutual to provide a photocopy of this release to any physician or medical institution to obtain records for the purposes stated above. This authorization will be valid for a period of two and one-half years for the purpose of collecting information regarding this Application. I authorize MMO/CLIC or its reinsurers to make a brief report of my personal health information to MIB.
2. I understand that the participation free life insurance benefits for which I am applying are subject to eligibility questions and I agree that I, as the Applicant, have answered the participation free eligibility questions to the best of my knowledge and belief. I also understand that if I answered “yes” to any of the participation free eligibility questions that I, am NOT eligible for the participation free life insurance benefits.
3. By signing below, I represent and warrant as follows: (a) I have thoroughly read and understand this Health and Life Application and the questions asked herein; (b) I have answered each and every question set forth in this Application; (c) all of my answers to each of the questions are accurate, complete and true and (d) I did not sign a blank or partially completed Application. I agree that Medical Mutual, in it’s sole discretion, may rescind my policy on the basis of any material misrepresentation or fraudulent response to any question in this Application. I further agree that if a policy is issued, it will be issued by Medical Mutual in full reliance and in consideration of the information, answers and statements contained herein.
4. I agree that: a) to be eligible for coverage, I must be an active full-time employee as defined by the policy(ies); (b) to be eligible for life and or disability income insurance, I must be actively at work as defined in the group policy. If I am not actively at work on the date my life and/or disability coverage would become effective, my life and/or disability coverage will begin on the day I return to work; and (c) if coverage is issued, it will be based on full reliance on the information contained in this Application.
5. I have read the sales materials and understand the plan benefits, exclusions, and limitations as outlined therein. I acknowledge that the managed care features of this health insurance policy (such as the preferred provider organization network) have been explained to my satisfaction. The applicable certificate or evidence of coverage will determine the rights and responsibilities of covered persons and will govern in the event they conflict with any benefit comparison summary or other description of the plan.
6. No issuance, waiver, modification or change of policy or any of Medical Mutual rules or amendments shall be binding upon Medical Mutual unless it is in writing and signed by an authorized officer of Medical Mutual, as applicable.
7. A permanent ID card will be issued following the final review and acceptance of this Application.
8. I understand and agree that I am solely and exclusively responsible for the truth, accuracy and completeness of all of the answers contained in this Application. I understand and agree that no agent or broker who may be assisting in the completion of this Application has any authority: (a) to waive any answer or any portion of any answer to any question on this Application or any information Medical Mutual requests; (b) to advise me that I am not obligated to disclose any condition of which I am aware concerning my health or the health of any dependent included on the Application; (c) to make any representation concerning health benefits that are inconsistent with, or different from, any written information provided by Medical Mutual; or (d) to bind Medical Mutual in any way by making any statement, promise or representation that is not set out in writing in this Application or regarding eligibility, benefits or issuance of a policy; (e) to answer any questions in, or insert any information on, this Application on my behalf; or (f) to approve coverage.
9. My dependents and I understand and agree that any information obtained will not be released by Medical Mutual to any person or organization except to reinsuring companies, the MIB, or other persons or organizations performing health care operations, payment related, or business or legal services in connection with any application, claim, or as may be otherwise lawfully required, or as we may further authorize. If a Consumer Reporting Agency is used, I (we) may request to be interviewed in connection with the preparation of the report. Once personal and health (including medical, dental, and pharmacy) information is disclosed pursuant to this authorization, it may be redisclosed by the recipient and the information may not be protected by federal and state privacy requirements. A copy of this authorization request is available to me or my legal representative upon written request. A photographic copy of this authorization shall be as valid as the original. This authorization shall be valid for a period of two and one-half years. I have the right to revoke this authorization at any time. To revoke this authorization, I must do so in writing and send my written revocation to Medical Mutual’s Privacy Office. The revocation will not apply to information that has already been released in response to this authorization. The revocation may adversely affect my application, a claim or a pending insurance action. The revocation will become effective after it is received by Medical Mutual Privacy Office. Your refusal to authorize the release of this information may impact your ability to enroll in Medical Mutual’s health plan if Medical Mutual needs this information to determine your eligibility for coverage.
10. I understand and acknowledge that this authorization extends to all medical records, including records which may contain information regarding treatment for physical and mental illness, alcohol/drug abuse and/or HIV – AIDS test results or diagnosis. I expressly consent to the release of such information.
11. If I am applying for coverage for my domestic partner, I represent and warrant that I and my domestic partner: 1) cohabit and reside together in the same residence and have done so for at least six months and intend to do so indefinitely; 2) are engaged in an exclusive and committed relationship and are financially interdependent; 3) are both at least 18 years of age and are each other’s sole domestic partner; 4) are not married or separated from anyone else; 5) have not had another domestic partner within six months of establishing the current domestic partnership; 6) are not related by blood; and 7) are not in this relationship solely for the purpose of obtaining insurance benefits.
Note: Main Account (mandatory) – This section must be filled in. This account will receive your entire net check. If you list any optional accounts below, this main account will receive the remainder of your check once the optional accounts are funded. **Unless otherwise noted, this account will be used for all misc. employee reimbursements. IMPORTANT: Please attach a voided check.
ACKNOWLEDGMENT: Please deposit my paycheck directly to my account(s) as indicated. I agree to notify the City immediately of any changes to the information so that my paycheck may be properly distributed. I understand that in the event my financial institution is not able to deposit my paycheck into my account due to any action I take; that I am responsible for any resulting bank fees incurred, and that the City cannot reissue the funds to me until the funds are returned to the City by my financial institution. Changes to direct deposit accounts must be given to the payroll department no later than the Friday prior to a pay week, changes received after Friday will not be applied until the following payroll. Please do not close your account(s) without giving us prior notice of the change.
CHECKING ACCOUNTS: Please attach a voided check. Deposit slips CANNOT be used. SAVINGS ACCOUNTS: Please obtain the required information from your financial institution. Routing numbers are still required on savings accounts. Deposit slips CANNOT be used.
Medical Mutual of Ohio complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex in its operation of health programs and activities. Medical Mutual does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex in its operation of health programs and activities.
Medical Mutual: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages
If you need these services or if you believe Medical Mutual failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, with respect to your health care benefits or services, you can submit a written complaint to the person listed below. Please include as much detail as possible in your written complaint to allow us to effectively research and respond.
Civil Rights Coordinator
Medical Mutual of Ohio
2060 East Ninth Street
Cleveland, OH 44115-1355
MZ: 01-10-1900
CivilRightsCoordinator@MedMutual.com
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
For elected officials: An elected official, or person appointed to a publicly elected position, who is not retired from an Ohio retirement system and does not have contributions on deposit with OPERS through previous elected service, has the option of contributing to OPERS or Social Security. Elected officials who choose OPERS membership are required to contribute to OPERS for all subsequent elected positions.
Click here for additional information about OPERS.
For additional OPERS forms & documents Click here.
Ohio Deferred Compensation is a supplemental 457(b) retirement plan for all Ohio public employees and one of the largest 457(b) plans in the country. Deferred compensation has been the Program’s only responsibility since 1976. Because of the Program’s size, plan expenses are low.
The Program provides participants with educational tools, a diverse set of investment options, flexible savings and withdrawal options, as well as portability when changing jobs within the public sector.
Click here for more information about Ohio Deferred Compensation Plan, where you can find helpful links, resources, and forms.
Instructions: List three PROFESSIONAL references who may be contacted by clicking Add Entry button, and click Submit for every consecutive entry.
Instructions: List training, licenses, office machines you can operate, typing speed, languages you speak fluently, etc. and any other skills which add to your qualifications.
Instructions: Please enter graduated schools by clicking Add School button. Fill out all necessary fields and click Submit for every consecutive entry.
Instructions: Please enter Occupational Licenses, Registration, Certificates by clicking Add Entry button, and click Submit for every consecutive entry.
Instructions: Please list below all work-related experience, starting with the most recent employment and working backwards. Provide a detailed description of regularly assigned ongoing duties for each job. Click Add Entry button, and click Submit for every consecutive entry.
Instructions: The following questions are necessary for the application to be processed. Please note, some questions require further explanation.
Form I-9 is used for verifying the identity and employment authorization of individuals hired for employment in the United States.
To learn more about Form I-9 Click here.
Click here to view the PDF file of the Instructions of I-9 Form.
Click here to view the PDF file of I-9 Form.
The City of Strongsville is an Equal Opportunity Employer and provider of ADA services.
Responses to the following questions are OPTIONAL. These questions are included to assist our equal employment opportunity efforts.
Providing this information is VOLUNTARY and will in no way affect the processing of your application or your being considered for
employment. Human Resources will process your responses to these confidential questions separately. Responses will be used for
statistical purposes only.
Explanation: Race/Ethnicity
WHITE: All persons having origins in any of the original peoples of Europe, North Africa or the Middle East. BLACK or AFRICAN AMERICAN: All persons having origins in any of the Black racial groups of Africa. HISPANIC or LATINO: All persons of Mexican, Puerto Rican, Cuban, Central or South America or other Spanish culture or origin, regardless of race. ASIAN: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent (for example, China, India, Japan and Korea). NATIVE HAWAIIAN or PACIFIC ISLANDER: All persons having origins in any of the original peoples of the Hawaiian Islands and Pacific Islands (for example, Hawaii, Philippine Islands and Samoa). AMERICAN INDIAN or ALASKAN NATIVE: All persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition. OTHER: Please self define.
Instructions: 1. For state purposes, an individual may claim only natural dependency exemptions. This includes the taxpayer, spouse and each dependent. Dependents are the same as defined in the Internal Revenue Code and as claimed in the taxpayer’s federal income tax return for the taxable year for which the taxpayer would have been permitted to claim had the taxpayer filed such a return.
2. You may file a new certificate at any time if the number of your exemptions increases. You must file a new certificate within 10 days if the number of exemptions previously claimed by you decreases because:
(a) Your spouse for whom you have been claiming exemption is divorced or legally separated, or claims her (or his) own exemption on a separate certificate. (b) The support of a dependent for whom you claimed exemption is taken over by someone else. (c) You find that a dependent for whom you claimed exemption must be dropped for federal purposes. The death of a spouse or a dependent does not affect your withholding until the next year but requires the filing of a new certificate. If possible, file a new certificate by Dec. 1st of the
year in which the death occurs. For further information, consult the Ohio Department of Taxation, Personal and School District Income Tax Division, or your employer.
3. If you expect to owe more Ohio income tax than will be withheld, you may claim a smaller number of exemptions; or under an agreement with your employer, you may have an additional amount withheld each pay period.
4. A married couple with both spouses working and filing a joint return will, in many cases, be required to file an individual estimated income tax form IT 1040ES even though Ohio income tax is being withheld from their wages. This result may occur because the tax on their combined income will be greater than the sum of the taxes withheld from the husband’s wages and the wife’s wages. This requirement to file an individual estimated income tax form IT 1040ES may also apply to an individual who has two jobs, both of which are subject to withholding. In lieu of filing the individual estimated income tax form IT 1040ES, the individual may provide for additional withholding with his employer by using line 5.
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The City of Strongsville is an Equal Opportunity Employer and provider of ADA services.
The City of Strongsville will not discriminate against any individual or group because of race, gender, sexual orientation, religion, age, height, weight, genetic information, national origin, color, marital status, political beliefs or disability. Applicants with a disability who may need an accommodation to complete the pre-employment application or participate in the interview process should make such a request to the City of Strongsville Human Resource Department.
Click here to read NOTICE OF EMPLOYMENT ACCOMMODATION