Election Form - Health Premium Pre-Tax Payments Page 2
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2Section B
Acknowledgment
■
I have received and read the Summary Plan Description for the Reformed Benefits
Association Master Flexible Benefits Plan.
■
I understand that my election can only be changed during the plan year under the
circumstances described in the Summary Plan Description.
■
I understand that if I do not make a new election during a subsequent open enrollment
period (December each year) that my current election regarding the health premium pre-
tax payments will be continued. However, I understand that the applicable premium
for coverage under the RBA’s Health Benefit Plan may be adjusted to the current
rate for that plan year.
■
If I elected to waive coverage under the RBA’s Health Benefit Plan as indicated under
Section A above, I understand that Employer is not liable for any expenses regarding a
non-work related injury or illness relating to me or any injury or illness relating to my
dependents.
Employee’s Signature
Date
This form is accepted and received by ___________________________________ [
print name of
].
Employer Representative
Signature of Employer Representative
Date
ADMINISTRATIVE USE ONLY:
Initial Election
Hire Date: _______________________________
Eligible Participation Date: _________________
Current Participant
Open Enrollment Date: _________________
Change in Status Date: __________________
st
Pay Date of 1
Deduction: _____________________
Deduction Amount: __________________________
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MJ_DMS 25920523v1 34753-1
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