Benefit Election. Check here if this election represents a change from last year’s enrollment. Indicate change here:
Benefit Election. [A(1) - Proof of Purchase with Claim Number] CLAIM NUMBER - You can find your Claim Number on the email or postcard you received notifying you about the Settlement [A(1)(i) - Claim Number found] Britax has records of your past purchase(s). You are eligible for either a partial cash refund or a voucher. Select the type of class benefit you choose to receive. (Choose only one.) [A(1)(ii) - Claim Number not found] [A(2) – Proof of Purchase without Claim Number] With valid Proof of Purchase, you are eligible for a partial cash refund or a voucher. Select the type of class benefit you choose to receive. (Choose only one.)
Benefit Election. Place an “x” in front of the type of class benefit you choose to receive. (Choose only one.)
Benefit Election. Do you wish to receive a Cash Payment or a Credit Certificate good toward the future purchase of Defendants’ products? □Cash Payment □Credit Certificate Inspection Demand – COMPLETE ONLY IF YOU SELECTED GROUP A IN RESPONSE TO QUESTION 1 ABOVE
Benefit Election. Full-Time Only Full-Time and Part-Time: Effective Date: _ / Plan Number (501, 502, etc): Open Enrollment Period: From: Through: Plan(s) Elected: HDHP/Basic MEC Plan / Advantage Plan / Both Employer Contribution Strategy: Fixed Dollar Amount: / Percentage of Premium: EE Status Premium Employer Contribution Full-Time Employees Employer Contribution Part-Time Employees EE Only $66.00 $ $ EE + Child(ren) $96.00 $ $ EE + Spouse $96.00 $ $ EE + Family $96.00 $ $ EE Status Premium Employer Contribution Full-Time Employees Employer Contribution Part-Time Employees EE Only $133.75 $ $ EE + Child(ren) $202.24 $ $ EE + Spouse $218.24 $ $ EE + Family $293.30 $ $ Payroll Deductions: (Initial)
Benefit Election. Please answer the following questions and check the corresponding box to confirm the benefit you are electing (if more than one option is provided).
Benefit Election. SPECIMEN To elect a benefit under this Rider: • You must request payment of the Rider benefit during Your lifetime in a written form; and • You must submit to us written proof that You qualify for the Rider benefit. You may only elect to receive benefits under this Rider once. At our expense, we may require an examination of You by a second Physician to verify any diagnosis or certification made by the initial Physician. The second Physician may be chosen by Us. If You are required by a government agency to use this Rider benefit in order to apply for, obtain, or keep a government benefit or entitlement, then You are not eligible to elect the benefit provided by this Rider. If any Owner dies before We make any payment under the terms of this Rider, We will consider the election to be null and void. We will pay the Beneficiary the Death Benefit as provided in the Contract when We receive due proof of death.
Benefit Election. The Executive elects the Benefit listed below next to which he or she has subscribed his or her initials. If no option is initialed, or if the Executive elects to defer his or her election of a Form of Retirement Benefit but thereafter fails to make a timely election, then the Executive’s Form of Retirement Benefit shall be the Post-Retirement Death Benefit provided for in Section 6(c)(i) of the Plan.
a. The Post-Retirement Death Benefit described in Section 6(c)(i) of the Plan, as modified herein. If the Executive elects or is deemed to elect the Post-Retirement Death Benefit, following modifications to the regular provisions of the Plan shall apply: (1) notwithstanding the regular Post-Retirement Death Benefit payment provisions and procedures provided in the Plan, if the Executive dies after he or she Retires and before the Endorsement Termination Date when his or her Post-Retirement Death Benefit is due under the Plan, the following steps shall occur promptly following the Executive’s death: (A) the Company and the Executive’s Beneficiary shall take all steps necessary to collect the gross proceeds under the Policy; (B) the Insurer shall pay the Executive’s Post-Retirement Death Benefit to his or her Beneficiary as specified in Schedule C; and (C) the Insurer shall pay to the Company the amount, if any, by which the gross proceeds under the Policy exceed the Post-Retirement Death Benefit; and (2) the Executive acknowledges that, under current law, he or she shall have taxable income equal to the value of the “economic benefit” derived by the Executive from the Policy’s insurance protection, as determined for Federal income tax purposes, after his or her Retirement and until the Endorsement Termination Date.
b. The Lump Sum Benefit described in Section 6(c)(ii) of the Plan.
c. The Salary Continuation Benefit described in Section 6(c)(iii) of the Plan.
d. If consented to by the Administrative Committee, the Joint and Survivor Insurance Benefit described in Section 6(d) of the Plan. NOTICE - IF MADE, THIS ELECTION IS IRREVOCABLE. THIS OPTION IS NOT CURRENTLY AVAILABLE. The Executive may revise his or her election only as provided in the Plan.
Benefit Election. The Executive elects the Benefit listed below next to which he or she has subscribed his or her initials. If no option is initialed, or if the Executive elects to defer his or her election of a Form of Retirement Benefit but thereafter fails to make a timely election, then the Executive’s Form of Retirement Benefit shall be the Post-Retirement Death Benefit provided for in Section 6(c)(i) of the Plan.
a. The Post-Retirement Death Benefit described in Section 6(c)(i) of the Plan.
b. The Lump Sum Benefit described in Section 6(c)(ii) of the Plan.
c. The Salary Continuation Benefit described in Section 6(c)(iii) of the Plan.
d. If consented to by the Administrative Committee, the Joint and Survivor Insurance Benefit described in Section 6(d) of the Plan. NOTICE IF MADE, THIS ELECTION IS IRREVOCABLE. THIS OPTION IS NOT CURRENTLY AVAILABLE. The Executive may revise his or her election only as provided in the Plan.
Benefit Election. To elect a benefit under this Rider: • You must request payment of the Rider benefit during Your lifetime in a written form; and • You must submit to us written proof that You qualify for the Rider benefit. You may only elect to receive benefits under this Rider once. At our expense, we may require an examination of You by a second Physician to verify any diagnosis or certification made by the initial Physician. The second Physician may be chosen by Us. If the opinion of the second Physician is different than the opinion of the initial Physician, the opinion of the second Physician will rule. If You are required by a government agency to use this Rider benefit in order to apply for, obtain, or keep a government benefit or entitlement, then You are not eligible to elect the benefit provided by this Rider. If any Owner dies before We make any payment under the terms of this Rider, We will consider the election to be null and void. We will pay the Beneficiary the Death Benefit as provided in the Contract when We receive due proof of death.
