FRESHWATER EDUCATION DISTRICT #6004 FLEXIBLE BENEFIT PLANFlexible Benefit Plan Election Form • October 15th, 2018
TOWN OF RIVERHEAD FLEXIBLE BENEFIT PLANFlexible Benefit Plan Election Form • November 27th, 2012
Prior to the first day of each plan year I will be required to complete a new Benefit Election Form. My election is effective for the plan year and may be changed during the year only for changes in family status (e.g., marriage or divorce, death of spouse or dependent, adoption or birth of child, certain changes in spouse's employment that affect health coverage).
ELECTION FORM AND COMPENSATION REDUCTION AGREEMENTFlexible Benefit Plan Election Form • November 9th, 2010
In accordance with my rights under the plan, I elect the following benefits and designate the following amount for the plan year 2011. The Employer and I agree that my cash compensation will be reduced by the amount set forth below for each pay period and plan year (Or during such portion of the year as remains after the date of this agreement).
