Bethel College
Benefits Election Form and Compensation Reduction Agreement
This form must be completed and turned in the Human Resource Office within 31 days from date of hire.
Mark accept election or decline and list the amount of coverage or benefit in the second column.
Enrollment forms are located on the Human Resources page of the Bethel College website at www.bethel-college.edu . TICUA and Guardian enrollment forms Must be completed if accepting or declining the election.
Employee Name
Benefit Elections / Declinations:
May 2009-April 2010
Benefit Plan: Coverage or Benefit Amount: Elections:
Health Insurance (complete enrollment for if selecting coverage, dropping coverage, or changing coverage)
q Accept Election (New premiums are listed)
Bronze Single ($46.00 monthly) EE+1 ($ 318.00 monthly) Family ($632.00 monthly) $______
Silver Single ($124.00 monthly) EE+1 ($441.00 monthly) Family ($814.00 monthly)
Copay Single ($122.00 monthly) EE+1 ($426.00monthly) Family ($787.00 monthly)
QHDHP Single ($35.00 monthly) EE+1 ($241.00 monthly) Family ($482.00 monthly)
q Decline
HSA election (complete enrollment form if QHDHP is selected and you are electing to make contributions)
q Accept Election
Maximum annual election is $3,000 single, and $5,950 family. Employees 55 and over can contribute an additional $1,000 per year. $______
¨ Decline
Dental Insurance (Complete enrollment form if selecting coverage, dropping coverage, or changing coverage)
q Accept Election
Single ($21.66 monthly) EE+1 ($48.68 monthly) Family ($84.98 monthly) $______
q Decline
Vision Insurance (complete enrollment form if selecting coverage, dropping coverage, or changing coverage)
q Accept Election
Single ($9.08 monthly) Two person ($13.80 monthly) Family ($24.24 monthly) $______
q Decline
FSA election (complete enrollment form if electing to make contributions)
q Accept Election (Maximum annual election is $5,000 medical and $5,000 dependent child care. Non-employer sponsored premiums are eligible for the FSA election) $______
q Decline
Guardian Life (complete enrollment form required for Employer provided life insurance and LTD benefits) $_No Cost to employee
Employee Name
Voluntary Life
¨ Accept Election (designate changes on Guardian enrollment form) $______
¨ Decline
Retirement (Bethel College match is 5% max )
¨ Accept Election (complete enrollment form and reduction agreement if selecting benefit) $______
(New enrollee’s as of 01/01/09 become 100% vested after three years)
¨ Decline
AFLAC (Contact AFLAC Representative Rita Woodson @ 731-352-0606)
□ Accept Election $______
□ Decline
Total Payroll Deduction Amount $______
______
With regard to my salary reduction agreement and my election of benefits, I understand that:
¨ I have received information providing a website location that contains a copy of the Summary Plan Description.
¨ I may not change elections during the plan year unless such events as the plan administrator determines will permit a change or revocation of an election as stated in the Summary Plan Description.
¨ The administrator is authorized to adjust the amount of my salary redirections and benefits if it is to necessary to satisfy certain provisions of the Internal Revenue Code or as a result of changes in premiums for benefits that are insured.
¨ My social security benefits may be slightly reduced as a result of Bethel College’s participation in a cafeteria plan under IRS code Section 125.
¨ I understand that I cannot revoke any pre-tax election based on a right to examine provision as may be contained in any insurance plan or policy issued to me. Rights to examine provisions contained within an insurance plan or
policy may be preserved by purchasing the plan or policy on an after-tax or individual basis.
¨ I understand that prior to each plan year I will be offered the opportunity to change my benefit election for the new plan year, although I may be required to submit evidence of insurability and/or be subject to late entrant penalties.
¨ I understand all of the benefit options available under the plan.
This agreement is subject to the terms of the company’s 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 compensation reduction agreement relating to such plan(s).
Employee Signature ______Date ______
Effective Date ___05/01/09______