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Benefit Election Form

Benefit Election Form and Salary Reduction Agreement

After filling out form, please scroll to the bottom and hit Submit.

    First Name

    M.I.

    Last Name

    Employer

    Employee Street Address

    City

    State

    Zip

    Email

    I hereby authorize and direct my employer to reduce my salary by pay period in the amount specified to pay for the coverages under the Premium Conversion and Reimbursement Accounts headings shown below. Such reductions, considered as elective contributions under the plan, will start with my first paycheck dated after the effective date of the plan. I further authorize future adjustments in the amount of the salary reduction in the event that the cost of coverage in any program selected below under the heading PREMIUM is changed by the carrier during the plan year. I also understand that the purpose of this program is to allow employees to select their qualified benefits within the guidelines of the Internal Revenue Code. I understand thtat the selection of a benefit and the indication that a premium is to be paid does not necessarily include me in the insurance portions of this plan. In most instances an application for insurance must also be completed. Listed below are the benefits that may be available under the plan. Please indicate which benefits you wish to select by completing the reduction per pay period cost. These selections will remain in effect undil a subsequent election form is filed, in accordance with the plan.

    Salary Reduction Amount Per Pay Period

    Premiums (Health Insurance/Employer Provided)

    (Such as: Blue Cross, Health Net, Kaiser, Delta Dental) Medical, Dental, Vision, Cancer, Other)

    Per pay period Pretax Deduction

    Reimbursement Accounts

    FSA Medical Expenses

    FSA Child Care

    Per pay period Pretax Deduction for Reimbursement Accounts

    Total Deductions per pay period

    Effective on Pay Period

    This election form will remain in effect and cannot be revoked or changed during the plan year, unless the revocation and new election are on account of and consistent with a change in family status.