Agenda Packets - 1988/08/08 - Laserfiche WebLink

Home Browse Search

HEALTH CARE AND DEPENDENT DAY CARE EXPENSE REIi1 CURSEMENT ACCOUNT , ENROLLMENT FORM 1 -1 New for Plan Year ❑ Change for Plan Year (complete Sections One and Two) (complete Sections One, Two and Three) SECTION ONE: EMPLOYEE DATA Last Name _ First Name MI Address — City — _ State _ Zip Code — SS# Sex Date of Birth _ Date of Hire SECTION TWO: ENROLLMENT ELECTIONS HEALTHCARE EXPENSE REIMBURSEMENT ACCOUNT: Please direct tho following amount, in equal amounts per paycheck, to my Health Care Expense Reimbursement Accoun': $ /year or $- /paycheck. If you do not wish to establish a Health Care Expense Reimbursement Account, place an "X" Lere ❑ DEPENDENT DAY CARE EXPENSE REIMBURSEMENT ACCOUNT: Please direct the following amount, in equal amounts per paycheck, to my Dependent Day Care Expense Reimbursement Account: $ --/year or$ /pavcheck. 11 you do not wish to establish a Dependent Day Care Expense Re'mbursement Account, place an "X" 1 here ❑ PRE-TAX PREMIUM ELECTION: Please withhold premiums from ny paychecks on a pre-tax basis for the Plan t. Year and use them tc pay for the foNowirg benefit coverages offered by my emp'oyer under life Plan: ❑ Medical ❑ Dental ❑ Other (Specify) — I hereby authorize my employer to make the pre-tax payroll deductions for the Plan Year, if any, which I have indicated above. I understand that the payroll deduction amounts above will be available for the reimbursement of my qualifying expenses incurred during the Plan Year and/or for the payment of my premiums in accordance with the terms of the formal Plan Documents. Employee Signature _ — Date SECTION THREE: ELECTION CHANGE Complete this section if you want to change your previous election effective for the current Plan Year. I hereby revoke my previous health care, dependent day care, and/or pre-tax premium authorizations for the current plan year and authorize my employer to make the pavnll deductions indicated by me in Section Two above fur the remainder of the Plan Year. The reason for the change is: Marriage ❑ I)Norce ❑ Death of Child or Spous9 ❑ Birth or Adoption of a Child ❑ Termination of Emolovment of Spouse ❑ Other (Explain) Employee Signature Date _ SECTION FOUR: FOR EMPLOYER USE ONLY Plan Sponsor (Employer) Division # Location — First Credit Date Effective Date Payroll Frequency Date Received _ Received by ifCharge, Change is_ _ Approved Denied Signature of Plan Administrator .— Date _ white = employer copy yellow - DrA, Inc. copy pink - employee copy