Section 125 Premium Only Plan Reduction Option
Benefit Election Form and Salary Reduction Agreement
Employee Name (Last, First, MI)Social Security No.
Employee Street AddressCity, State, Zip Code
It is open enrollment for the Premium Only Plan. Please sign this form to either authorize participation in this plan or decline participation in this new plan year. The benefits that are included under the plan (as applicable): Medical, Dental, and Vision premiums and Health Savings Account contributions.
This election form will remain in effect and cannot be revoked or changed during the plan year, unless the revocation and new election are acceptable/eligible under the Regulations issued by the Department of Treasury. Acceptable/eligible changes include:
- Marriage
- Divorce, Legal Separation, or Annulment
- Birth, or adoption, or placement for adoption of a child
- Death of my spouse and/or dependent
- Termination or commencement of employment by my spouse or dependent
- I, my spouse, or dependent have had a change in employment status, including a strike or lockout that affected eligibility for benefits.
- A change in the residence or worksite of myself, my spouse, or dependent that affected eligibility for benefits
- My dependent satisfies or ceases to satisfy the requirements for coverages due to attainment of age, student status, or any similar circumstance.
- A cost or coverage change in benefits that affected eligibility for myself, my spouse, or dependent
- I have medical, dental or vision coverage elsewhere.
- Individual medical open enrollment in State Marketplace allows termination of group coverage for yourself, your spouse, or your child(ren) during the open enrollment period offered by the state Marketplace for individual medical coverage. You must intend to enroll in an individual medical plan through your state’s Marketplace no later than the day following the termination of coverage under this group plan.
- Reduction of hours below 30 hours per week as a result of a change in employment status allows termination of group coverage for yourself, your spouse, or your child(ren) from your employer-sponsored health coverage midyear (whether or not eligibility for the coverage is affected) if the you intend to enroll in another plan offering minimum essential coverage.
While it is not obvious, it is important to point out that financial hardship is not an acceptable/eligible change of status reason. If enrolled in the Premium Only Plan, you may not change your salary reduction election by terminating your insurance coverage mid-plan year, if you are responsible for a portion of the insurance premium. If enrolled in the Premium Only Plan, you may not change your salary reduction election by terminating your dependents insurance coverage mid-plan year, if you are responsible for all or a portion of the insurance premium.
To Authorize Participation: I hereby certify the above information to be correct and true and choose to participate.
Signature______Date______
To Decline Participation: The benefits of the plan have been thoroughly explained to me, but I choose not to participate.
Signature______Date______