Oae-Meritec 401k Enrollment / Contribution / Change Form

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OAE–Meritec 401K Enrollment /

Contribution / Change Form

Innovative-Interconnect Solutions

A s s o c i a t e d E n t e r p r i s e s / M e r i t e c

Changes can be made by currently enrolled employees at the beginning of each quarter.

Employee Name ____________________________________________________________________________________

(Please Print)

Date Requested ____________________________________________________________________________________

Percentage Change _________________________________________________________________________________

Dollar Amount Change _______________________________________________________________________________

Effective Payroll Date ________________________________________________________________________________

401K ELECTIONS – 2016

Please check only one response and return to Brenda Rife

I am currently enrolled in the 401K Plan and do not wish to change anything at this time. Beneﬁ ciary Form (below).

I am currently enrolled in the 401K Plan and wish to make changes. Application is attached and Beneﬁ ciary Form (below).

I am currently enrolled in the 401K Plan but not participating – I wish to join at this time. Application is attached and

Beneﬁ ciary Form (below).

I am currently enrolled in the 401K Plan, but not actively participating. Beneﬁ ciary Form (below).

I would like to enroll as a New Member of the 401K Plan. My New Application is attached and Beneﬁ ciary Form (below).

I am currently enrolled in the 401K Plan and wish to discontinue contributions at this time. Beneﬁ ciary Form (below).

I do not wish to participate in the 401K Plan at this time.

Attachment(s): _____________

COMPLETE INFORMATION BELOW FOR YOUR 401K BENEFICIARY (ies)

Primary Beneﬁ ciary Name(s) – Must Add Up To 100%

Relationship

% Beneﬁ t

Phone

Address

Optional Contingent/Secondary Beneﬁ ciary Name(s)

Relationship

% Beneﬁ t

Phone

Address

I agree that: (a) any untrue or incomplete information, statement or answers on this Application (whether or not intentional), can result in denial of a claim or rescission of coverage and may subject me to legal action by the Plan; (b) to

be eligible for coverage, I must be an active eligible participant as deﬁ ned by the policy(ies); (c) to be eligible for life and or disability income insurance, I must be actively at work as deﬁ ned in the group policy. If I am not actively at work

on the date my life and/or disability income coverage would become effective, my life and/or disability coverage will begin on the day I return to work; (d) if coverage is issued, it will be based on full reliance on the information contained

in this Application.

I am signing this Application on my own behalf and on behalf of all listed dependents. An unaltered copy or electronic reproduction of this authorization is as valid as the original. I have read all of the statements contained in this

Application, and declare by signing this Application that my dependents and myself are hereby eligible for coverage after review of the Plan’s eligibility parameters. All information that I have provided is true and complete to the best of

my knowledge.

Furthermore, I understand that if no coverage has been elected or I have selected a waiver, I hereby refuse the Plan offered by my employer and recognize that my future enrollment may be subject to certain restrictions as deﬁ ned by

the Plan. By enrolling, I authorize payroll deductions that are required for the beneﬁ ts that I elect. I understand that my elections are irrevocable unless I have a Qualiﬁ ed Status Change. In addition, I understand that the beneﬁ ts for

which I have enrolled may not be immediately available or available to me based on eligibility exclusions, limitations or waiting periods and ﬁ nal coverage requires certiﬁ cation by human resources before is shall be activated.

__________________

Employee Signature

Date

ASSOCIATED ENTERPRISES

• 1382 WEST JACKSON STREET • POST OFFICE BOX 110 • PAINESVILLE, OHIO 44077

Rev. 061416

PHONE: (440) 354-2106 • FAX: (440) 354-0687 • • E-MAIL: