This form can be used to authorize new benefit deductions, request changes to current deductions and/or cancel benefit deductions.
Employee Information – Complete this section in its entirety.
Employee name: ______________________________________________
Social Security number:_________________________________________
Home address: _______________________________________________
City, State, Zip: _______________________________________________
Hire date: ____________________________________________________
Job title and department: ________________________________________
Add Payroll Deductions – Complete this section to authorize payroll deductions.
Benefit type: ___________________________________________________
Level of coverage: ______________________________________________
Biweekly payroll deduction: _______________________________________
Effective date: __________________________________________________
I authorize the above pre-tax salary deductions to be withheld from my bi-weekly pay. I authorize deduction rate increases or changes as required by the benefit provider in accordance with the terms and conditions of my policies.
Pre-tax benefit changes are subject to the mid-year election change rules outlined in the benefit summary plan description.
Employee signature: ________________________ Date: __________
Change Payroll Deductions – Complete this section to authorize to payroll deduction changes.
Benefit type: ___________________________________________________
Level of coverage: ______________________________________________
Reason for the change: _______________________________________
Effective date: __________________________________________________
Pre-tax benefit changes are subject to the mid-year election change rules outlined in the benefit summary plan description.
I authorize the above pre-tax salary deductions to be withheld from my bi-weekly pay. I authorize deduction rate increases or changes as required by the benefit provider in accordance with the terms and conditions of the benefit policies.
Employee signature: ________________________ Date: __________
Cancel Payroll Deductions – Complete this section to stop payroll deductions.
Benefit type: ___________________________________________________
Level of coverage: ______________________________________________
Reason for cancellation: _______________________________________
Effective date: __________________________________________________
Pre-tax benefit changes are subject to the mid-year election change rules outlined in the benefit summary plan description.
I no longer desire to participate in the pre-tax salary deduction program for the above listed benefits. Please cancel the above deductions as of the above effective date.* Deduction cancellation requests must be received eight work days prior to the effective pay date.
Employee signature: ________________________ Date: __________
*Cancellations and changes to payroll deductions will normally be effective the pay period following the date on this form. Retroactive changes are not authorized.