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CAFETERIA PLAN

Election Form and Compensation Redirection Agreement

 

Company Name

 

Employee Name ________________________________________ Employee Address ____________________________________________

 

 

Employee Social Security Number ________________________________________________ Hire Date _____________________________

 

 

Date of Birth ____________________ Marital Status ____________________ Sex: OM OF

 

 

Plan Year ________________________________ through __________________________________ Effective Date ___________________________

 

 

The Company and I hereby agree that my cash compensation will be reduced by the amounts set forth below for each pay period during the plan year (or during such portion of the year as remains after the date of this agreement).

 

Election and Compensation Reduction Agreement for Coverage Under Certain Benefit Plans

 

On the appropriate benefit enrollment form(s), I have enrolled for certain dental, disability, life insurance, and/or health insurance coverages. I elect to receive the following coverage under the Cafeteria Plan.

 

BENEFIT ELECTION - I elect to allocate the following amount on a MONTHLY basis to the purchase of the benefits chosen below, I understand that my monthly compensation shall be reduced by dollar amounts for the levels indicated to create flexible benefit plan dollars during the plan year.

                          Employee                                Employer

                          Portion               Monthly       Portion

LEVEL I         O Medical $_________                                                                     $_________                                                       LEVEL II     0 Unreimbursed Medical $                                    Mi.

                        O Dental  $__________                                                                     $__________                                                                                                                           Insurance deductible/uninsured/out-of-pocket medical cost

                        O Life       $_________                                                                      $_________                                                       LEVEL III    0 Dependent Care               $                                                                                                                                          Mn.

                        O Other    $_________                                                                      $_________                                                                                                                               Care for a child, disabled spouse or dependent

 

Note: There may be limits on the amounts which can be used for certain benefits. You should review your Summary Plan Description and ask your Administrator if you have any questions.

 

With regard to my salary redirection agreement and my election of benefits, I understand that:

 

•    I may not change elections during the Plan Year unless there is a change in my family status (e.g., marriage, divorce, death of my spouse or child, adoption or birth of my child, or termination of employment of my spouse).

•    The Administrator is authorized to adjust the amount of my salary redirections and benefits if it is necessary to satisfy certain provisions of the Internal Revenue Code or as a result of changes in premiums for benefits that are insured.

•    My election of salary redirections and benefits will remain in effect only for the Plan Year for which these elections are made. Failure to sign a new election form during the election period prior to each subsequent Plan Year will be considered an election not to participate in the Plan for that Plan Year.

•    Any amounts that are not used during a Plan Year to provide benefits will be forfeited and may not be paid to me in cash or used to provide benefits In a later Plan Year.

•    My Social Security benefits may be slightly reduced as a result of my election.

In the event of my death, my designated beneficiary may have certain obligations and responsibilities to file claims and seek the payment of benefits under the terms of the Plan. I therefore designate as my beneficiary under the Plan:

 

NAME AND RELATIONSHIP

 

ADDRESS

 

I hereby authorize the Company to withhold a service fee of$_____________ per month from my compensation for administrative costs of the Plan.

 

THIS AGREEMENT IS SUBJECT TO THE TERMS OF THE COMPANYS CAFETERIA PLAN, MEDICAL REIMBURSEMENT PLAN, AND/OR

DEPENDENT CARE ASSISTANCE PLAN AS AMENDED FROM TIME TO TIME IN EFFECT, SHALL BE GOVERNED BY AND CONSTRUED

IN ACCORDANCE WITH APPLICABLE LAWS, SHALL TAKE EFFECT AS A SEALED INSTRUMENT UNDER APPLICABLE LAWS, AND

REVOKES ANY PRIOR ELECTION AND COMPEN- SATION REDUCTION AGREEMENT RELATING TO SUCH PLAN(S).

 

X_________________

Employee Signature

 

 

WAIVER

For the period______________________through _____________________________ I have been offered the opportunity to participate in the Cafeteria Plan and I decline. I understand that if I  should later desire to participate I will have to wait until the next Plan Year unless I experience an official change in family status.

Employee Signature  x__________________________________________________                                                           Date ______________.