SECTION 125 PLAN Benefit Election Agreement Plan Year Beginning: January Participant Name (Print)

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Ezra Harper
6 years ago
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1 SECTION 125 PLAN Benefit Election Agreement Plan Year Beginning: January 2012 Participant Name (Print) As an eligible participant in the Muhlenberg College Section 125 Plan, I hereby elect the following benefits. My share of the cost of these benefits will be paid through an adjustment to my taxable compensation beginning with the next payroll date subsequent to the date of my signature below. Indicate who you are covering on your insurance by checking the boxes that apply: A. Highmark Blue Shield PPO 1 Individual (Employee ONLY) 2 2-Party (Employee + Spouse/Partner* ) -or - Employee + Child 3 Family(Employee + Spouse/Partner * + Child(ren) -or- Employee + Children * Surcharge may apply to cover your spouse/partner (Complete the Spouse/Partner form) B. Vision 1 Individual (Employee ONLY) NO COST 2 2-Party ($9.00/month) (Employee + Spouse/Partner or Employee + Child) 3 Family($9.00/month) (Employee + Spouse/Partner + Child(ren) or Employee +Children) C. Concordia Preferred Dental 1 Individual (Employee ONLY) 2 2-Party (Employee + Spouse/Partner) -or- Employee + Child 3 Family (Employee + Spouse/Partner + Child(ren) or Employee + Children I understand that: I cannot change or revoke this agreement at any time during the Plan Year unless I have a change in family status, as defined by the Plan. I may make changes to my coverage and/or pre-tax election during the Open Enrollment period, to take effect the following January 1. Any reduction in my income subject to FICA taxes may affect my Social Security benefits at retirement and/or upon disability. This election will remain in effect for subsequent years unless changed by me prior to the first day of succeeding years. For the benefits checked above, I (check one) Elect the pre-tax option Decline the pre-tax option Signature PLEASE RETURN ALL FORMS TO HUMAN RESOURCES If you are covering a spouse, please complete the Spouse Certification Form

2 Spouse Coverage Effective January 1, 2012 Dear Employee: We are pleased to continue Health Insurance coverage for our employees and dependents and continue to look for ways to control our health care costs. Muhlenberg College will continue to offer medical insurance coverage for a spouse who is unemployed, a spouse who is employed but has no medical insurance available through the spouse s employer, or a spouse who is employed but whose employer does not contribute 70% or more towards the health insurance premium. Muhlenberg College will continue to offer medical coverage for your children who qualify under the health plan, regardless of the employment status of your spouse. You may elect medical coverage for any spouse who is eligible for coverage or covered under his or her employer s health plan to which the employer contributes 70% or more toward the premium for an additional surcharge of $50 per month on a before tax basis. If you are married, please complete the following certification, sign it, and return it to me within 5 days. Accurate completion of this certification is considered a condition of continued employment by Muhlenberg College. CERTIFICATION OF SPOUSE S EMPLOYMENT STATUS AND MEDICAL INSURANCE AVAILABILITY I,, hereby certify that: (please PRINT employee s name) My spouse is unemployed. My spouse is employed but is not eligible for medical insurance through his/her employer. (If your spouse had previously waived coverage at his/her own employer, he/she would be eligible to enroll in that employer s plan at this time due to HIPAA's special enrollment rights, providing that company s eligibility requirements are met.) My spouse is employed and is eligible for medical insurance through his/her employer. The employer does contribute 70% or more of the health insurance premium ($50/month surcharge applies). Have your spouse complete the Health Insurance Verification Form and submit to their benefits department for verification of coverage. does not contribute 70% or more of the health insurance premium (employer verification required). Employee s Signature

3 If you are covering your spouse, please have them complete this form and present it to their benefits department for verification of coverage. HEALTH INSURANCE VERIFICATION TO: HUMAN RESOURCES RE: Employee Name Spouse/partner of: Muhlenberg College Employee My signature below authorizes your release of information to my spouse s employer, Muhlenberg College. Signature of Employee Named Above Does the above named employee have access to health insurance through your company? YES NO If YES, does your company pay less than 70% of the individual premium? YES NO Name of Company Human Resources Representative (Please Print) Signature of HR Representative Please return this form to: Muhlenberg College Human Resources 2400 Chew Street Allentown, PA Phone: (484) FAX: (484)

4 Participation and Salary Reduction Agreement Plan year: January 1, 2012 through December 31, 2012 I. Participant Identification (please print or type) Participant Name: Social Security Number: / / Address: DOB: / / City: State: Zip: II. Agreement to Participate and Salary Reduction Agreement Please check below your benefit choices. Sign and date the form and return to the Human Resources Office. Check the boxes for the benefits you are selecting and indicate the amount of salary reduction for each pay period for the Medical Flexible Spending Account and Dependent Care Flexible Spending Account. I hereby authorize my employer to reduce my cash compensation as indicated below for each pay period during the Plan Year following the date of this agreement. Flexible Spending Arrangements Salary Reduction Number of Annual Per Pay Pay periods Election (Round to nearest whole dollar) Dependent Care FSA (not to exceed $ annually) X = $ Medical Expense FSA (not to exceed $ annually) X = $ Waiver I decline participation in the Flexible Benefits Plan I understand that this election form cannot be revoked or changed during the plan year, unless there is a change in my family status (e.g. marriage, divorce, death of spouse or child, birth or adoption of child, and termination of employment of spouse) which justifies the revocation or change. I understand that salary reductions must be reimbursed for qualified expenses incurred during the plan year and may not be carried over into future plan years. If at the end of the plan year, the total reduction in compensation exceeds the substantiated expenses, the difference in amounts will be the property of the employer. I have examined this agreement and to the best of my knowledge, it is true, correct and complete. Participant's Signature Agreed and accepted by The Employer's Representative (Admin. Only): Effective : / / 1 st Withholding: / / PLEASE RETURN ALL FORMS TO HUMAN RESOURCES

5 WAIVER OF HEALTH CARE BENEFITS I understand that I am eligible for College-sponsored health care benefits. However, I choose not to be enrolled in the College plan as of the date noted below for the reason stated. I understand that should conditions of my spouse s employment or other appropriate personal circumstances necessitate my or my dependents enrollment in a College plan in the future; I have the right to enroll at that time. I further understand my right as an employee to enroll during any open enrollment period for any reason. I understand that, under the Consolidated Omnibus Budget Reconciliation Act (COBRA), if I am signing this waiver upon termination, I have the right to change this voluntary election for up to sixty days following my termination. Name (Printed): Signature: Effective date of Waiver: / / _2012 Month Day Year Reason for Waiver: If covered elsewhere (for example, by a spouse), please list the name, employer, insurance company and group number of the person who provides your coverage. Name: (If covered by spouse, spouse s name) Spouse s Employer: Insurance Company: (i.e., Capital Blue Cross, Highmark Blue Shield, Aetna US Healthcare, etc.) Group Number: RETURN FORM TO HUMAN RESOURCES

Initial Notice Form COBRA Notice Upon Enrollment in a Group Health Plan

Initial Notice Form COBRA Notice Upon Enrollment in a Group Health Plan VERY IMPORTANT NOTICE If a qualifying event occurs that causes you or your spouse or dependent children to lose coverage under group