FairfieldCounty

Health and Life Insurance Authorization Form

new hire enrollment Information

Name: ______

Social Security Number: ______- ______- ______

Department: ______Hire Date: ______

A new employee must notify the payroll department of his or her decision regarding health insurance enrollment within thirty days of his or her hire date. This format serves as authorization for appropriate payroll deductions for the employee portion of this insurance premium.

Health insurance becomes effective the first day of the month after hire date. Life and Long Term Disability insurance and is effective on the initial hire date. For example, an individual who was hired 1-15-xx will have health coverage beginning on 2-1-xx and Life insurance and LTD coverage beginning 1-15-xx.

To make an election, check ONE of the following statements.

Payroll Deduction Election
I wish to have Family health insurance coverage. I hereby authorize my employer to deduct any applicable employee’s share of premiums that pertain to my department for health insurance from my earnings.
I wish to have Single health insurance coverage. I hereby authorize my employer to deduct any applicable employee’s share of premiums that pertain to my department for health insurance from my earnings.
Cafeteria Plan Election – Salary Redirection Agreement.
If I selected health insurance coverage with a payroll deduction, I further elect that the payroll deduction shall be:
______Pre-Tax (or) ______After-Tax
(Reduces tax liability)
I cannot change or revoke this Salary Redirection Agreement with respect to Pre-tax premiums before the next anniversary date of the plan unless a change in family status occurs (i.e., marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of employment of a spouse and such other events as will permit a change or revocation of an election under the Internal Revenue Code, as amended), an the change is caused by and consistent with the Change in Family Status. Due to federal tax law, an election for a Pre-tax Benefit is irrevocable, except as otherwise indicated in the preceding sentence. I understand this pre-tax election and authorization will continue indefinitely, does not require my annual recertification, and can only be changed or revoked as indicated above.

-or -

No Payroll Deduction Election
I do not want health insurance coverage and wish to have only basic life insurance and LTD insurance coverage. There will be no deduction taken from my pay.
I wish to have Family health insurance coverage. I understand my department pays the entire premium (per department policy) in this case, and there will be no deduction taken from my pay.
I wish to have Single health insurance coverage. I understand my department pays the entire premium (per department policy) in this case, and there will be no deduction taken from my pay.

______

Signature of Employee Date

For payroll department use:

$______1/1____ to 12/31______

Employee Deduction Sub-Group # Effective Date Plan Year Deputy Initials

Revised 3/1/05Page 1 of 1Form# FCP-05