1992 - 06-15-92 Regular Meeting - Laserfiche WebLink

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BbU'~ ~-1 Prr~ 1 ' lexible Benef its Plan Premium Conversion Plan Election Form Employer Name (Print and please press hard ) ]T I NOeparlment Name (Last. First, Mddle) social sacmity No. E Employee Street Add'.. city slate Please complete all the above Information for all plan participants. ❑ Married ❑ Male No. of deduction periods Hours regularly worked each week ❑ Single ❑ Female per year for this employer I understand that my employer, , is providing 5 per pay period for the purchase of qualified benefits as part of a flexible benefits plan under Section 125 of the Internal Revenue Code. I also understand that I have an amount of flexible pay equal to $ per pay period. I hereby authorize and direct my employer to reduce my salary in the amount necessary to pay for the coverages shown below. Such reductions, considered as Elective Contributions under the Plan, shall commence with my paycheck dated . I further authorize future adjustment in the amount of the salary reduction in the event that the cost of coverage in any program selected is changed 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, and that I may select either cash or qualified benefits, or a combination of both. Listed below are the benefits available under the Plan. Please indicate which benefits you wish to select by completing the total cost and the amount to be Employer Paid or paid by Salary Reduction. The selections will remain in effect until a subsequent election form is filed. BENEFIT' Hospital Income - Employee Only Hospital Income - Employee & Dependent Sickness - Employee Only Sickness - Employee & Dependent Accident - Employee Only Accident - Employee & Dependent Cancer - Employee Only Cancer- Employee & Dependent Total Employer Salary Reduction Cost Paid Amount Per Pay Period Cash Totals '1 understand that the selection of a benefit, and the indication that a premium is to be paid, does not necessarily include me to the insurance portions of this program. In most instances, an application for insurance must also be completed. 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 (e.g., marriage, divorce, death of spouse or child, birth or adoption of child, and termination of employment of spouse). I understand that the insurance claim payments under certain coverages may be subject to Federal and State taxes when the premium is paid by salary reductions or employer contributions. 46~ Signature Date IF YOU DECLINE PARTICIPATION: The benefits of the plan have been thoroughly explained to me and I decline to participate. 36