PREMIUM CONVERSION ACCOUNT. 1. Select the types of Contracts with respect to which a Participant may contribute under the Plan: a. [ X ] Employer Health b. [ X ] Employer Dental
PREMIUM CONVERSION ACCOUNT. I request that my taxable wages each pay period be reduced by my share of any Health insurance premiums payable under any employer-sponsored health plan in which I am a participant and that my employer use the salary-reduced amounts to pay my share of the premiums. Pursuant to P.L. 2011, Ch. 78, the amount of each employee’s health benefit deduction is calculated as follows: Premium Amount Per Employee x Statutorily Mandated % of Premium = Employee Health Benefit Premium Deduction. Accordingly, I understand that my salary reductions for this benefit will automatically change due to changes in the premium arrangements (e.g., an increase in premiums or an increase in the share of these premiums I may have to pay). Pre-tax elections cannot be changed or revoked prior to the next anniversary date, unless due to a change in family status and permitted by the employer. ☐ I don’t wish to participate in the Health Premium Conversion Spending Account. I understand that my salary-reduced amounts to pay my share of the health premiums will be taxable. ☐ Health Care Opt-Out. I wish to opt out of the following insurance coverage for the _ 2022 calendar year. ☐ Medical Insurance ☐ Dental Insurance ☐ Prescription Insurance I understand that I must provide proof of alternate coverage for myself and all presently covered dependents. (Only need to do this when signing up for Opt Out). I understand that I will receive an opt-out payment according to my collective bargaining agreement. I understand that this agreement is irrevocable except for certain changes specifically set forth in the plan documents. The amounts cannot be transferred from one account to another, carried over beyond the year to which this agreement relates or returned to me in cash or other remuneration. Revision Changes in Status (Check one) Legal Marital-Marriage, Death of Spouse, Divorce, Legal Separation or Annulment Changes in Dependent’s Status-Requirements for Coverage Due to Age. Student Status or Similar Circumstance. Cobra, Medicare or Medicaid Change in Cost of Coverage # of Dependents-Birth, Adoption or Death Employment-Termination or commencement or commencement by Employee, Spouse or Dependent Work Schedule P/T, F/T, Strike, reduction or increase in hours or unpaid leave. Residence or Worksite-change for Employee, Spouse or Dependent Judgment, Decree or Order PLEASE PRINT NAME
PREMIUM CONVERSION ACCOUNT. NOTE: If Premium Conversion Account is not a selected Benefit under A.5a, Section D is disregarded.
