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attachmentPremium Only Plan (POP) Flexible Benefits Election Form

ALL EMPLOYEE SHOULD SUBMIT FORM TO PAYROLL

This is not an enrollment form for insurance benefits.  If you wish to add or change coverage, please sign into your account on the Employee Navigator at:

https://www.employeenavagitor.com/benefits/Account/Login

Salary Reduction and Benefit Elections

Your salary reduction and benefit elections must remain in effect until the end of your plan year (June 1 through May 31). Changes may be made only if there is a change in your status.

If there is a change in status, the Payroll Dept. MUST BE CONTACTED WITHIN 30 DAYS OF THE QUALIFYING EVENT for modifications to the current plan.

SALARY REDUCTION INFORMATION

1)  Your salary reduction and benefit elecitons must remain in effect until the end of your plan year (through May 2019).  Changes may be made  only if there is a change in your status.  A qualifying change in your marital status includes marriage, divorce, death of a spouse, legal separation, and annulment.  Events that change your number of dependents include birth, death, adoption, and placement for adoption.  Events that change the employment status of an employee, spouse, or dependent include termination or commencement of employment, a strike or lock-out, a commencement of or a return from unpaid leave of absence, and a change of work-site.  Events that change a dependent's status are attainment of age 26 or they obtain coverage from another source.  If there is a change in status, the payroll department must be contacted within 30 days of the qualifying event for modifications to the current plan.

2)  If the cost of a benefit package option significantly increases during the period of coverage, you may increase your payment or revoke your election and receive similar coverage under another benefit package option.  If the cost of  benefit package option significantly increases during the period of coverage, you may increase your payment or revoke your election and receive similar coverage under another benefit package option.

3)  If the cost for your elected Insurance premium benefits is increased or decreased while this agreement is in effect, your salary reduction will automatically be adjusted to reflect the increase or decrease.

4)  Prior to the end of the plan year (May 31, 2019) you will be given the opportunity to change your salary reduction and benefit elections for the next plan year.

5)  It is your responsibility to determine whether the Flex Plan is on any income tax consequence to you. 

What is a Qualifying Event?

These events include:

Change in marital status -
Marriage, divorce, death of a spouse, legal separation and annulment.

Change in your number of dependents -
Birth, death, adoption of child or placement for adoption.

Change in employment status -
Of an employee, spouse, or dependent include termination or commencement of employment, a strike or lock-out, a commencement of or return from an unpaid leave of absence.

Change of a dependent's status -
Attainment of age 26 or they obtain coverage from another source.
Change in your employment status.
Change in your spouse's employment, impacting his/her benefits eligibility.

Non-Qualifying Life Events

Some examples of events that do not allow you to change your flexible benefit elections:

Re-hired within 30 days of termination date.
The benefit cost is too high/you did not realize how much was going to come out of your paycheck.
You decided you do not like the coverage.
You need more money in your paycheck.