Election Form - Health Premium Pre-Tax Payments printable pdf download

Election Form - Health Premium Pre-Tax Payments

REFORMED BENEFITS ASSOCIATION

MASTER FLEXIBLE BENEFITS PLAN

ELECTION FORM

HEALTH PREMIUM PRE-TAX PAYMENTS

Plan Year ending December 31, 20__

EMPLOYEE INFORMATION:

Name (print):

Address:

 Full-time  Part-time

Position:

Reason for completing this Election Form:



Initial Election (Election is effective on the date your participation in the

RBA’s Health Benefit Plan begins.)



Open Enrollment (Election is effective January 1 of the next plan year.)



Change in Status (Election is effective on the date of the change.) A

completed Change in Status Form must be attached.

Section A

Health Benefit Plan

Premium Pre-Tax Payments



I elect to pay, on a pre-tax basis, the applicable premium for the coverage I elected

under a Health Benefit Plan made available through the RBA (the RBA Health Benefit

Plan). I understand that my compensation will be reduced in equal amounts from my

paychecks during the plan year according to the required premium contribution. In

addition to completing this form, I understand I must also complete the enrollment

process in connection with the Health Benefit Plan.



This section does not apply to me because I elected to waive coverage under the RBA’s

Health Benefit Plan.

Election Form - Health Premium Pre-Tax Payments