* indicates REQUIRED information


Name:
SSN:
Gender:
Birthdate:
Address: Address2:
City:
St:
Zip:
Division:
Hire Date:
Job Title:
Salary:
-----------------
MEDICAL UHC
-----------------
Plan1 - AHJC PRO
Employee Only: $27.00
Employee & Spouse: $143.88
Employee Child(ren): $98.14
Full Family: $206.55

Plan2 - BA3C HMO
Employee Only: $49.99
Employee & Spouse: $198.59
Employee Child(ren): $140.44
Full Family: $278.28

Plan3 - AQPW HMO
Employee Only: $55.31
Employee & Spouse: $211.25
Employee Child(ren): $150.23
Full Family: $294.87

* WAIVE MEDICAL COVERAGE
** I have other medical coverage (Medicare/TriCare/Spouse's Plan, etc.)
*** I do not have other medical coverage

-----------------
DENTAL UHC
-----------------
Plan - LOW
Employee Only: $7.14
Employee & Spouse: $15.13
Employee Child(ren): $18.30
Full Family: $27.40

Plan - HIGH
Employee Only: $8.11
Employee & Spouse: $17.18
Employee Child(ren): $20.79
Full Family: $31.12

* WAIVE DENTAL COVERAGE

-----------------
VISION UHC
-----------------
Employee Only: $1.66
Employee & Spouse: $3.32
Employee Child(ren): $3.65
Full Family: $5.31

*WAIVE VISION COVERAGE

-----------------
DISABILITY UHC (See Benefits Booklet or click HERE for rates)
-----------------
Short-Term Disability (Weekly Deduction): $____________

* WAIVE Short-Term Disability Coverage

Long-Term Disability (Weekly Deduction): $____________

* WAIVE Long-Term Disability Coverage

-----------------
VOLUNTARY LIFE INSURANCE UHC (See Benefits Booklet or click HERE for rates - $0.16/week covers all children)
-----------------
Employee Benefit:
Voluntary Life Insurance Deduction Amount - $____________
(Guaranteed Issue*: $100,000)

*WAIVE Employee Life Insurance

Spouse Benefit*:
Voluntary Life Insurance Deduction Amount - $____________
(Guaranteed Issue*: $25,000)
**Cannot exceed 50% of Employee Voluntary Life

*WAIVE Spouse Life Insurance

Child(ren) Benefit*:
Voluntary Life Insurance Deduction Amount - $____________
____ $500 Benefit (Under 14 Days)
____ $10,000 (14 Days and over)

*WAIVE Child(ren) Life Insurance

*You must complete an "Evidence of Insurability" form if electing an amount over the "Guaranteed Issue" amount

-----------------
FLEXIBLE SPENDING ACCOUNT (FSA)(Election listed below will be divided by 52 paychecks)
-----------------
___ Flexible Spending Annual Election: $___________

*WAIVE Flexible Spending Account

___ Dependent Day Care Annual Election: $___________

*WAIVE Dependent Day Care Account

**2020 Maximum Plan Year Contributions:
Health Care FSA: $2,700
Dependent Day Care: $5,000 ($2,500 if Married filing Separately)

Salary Deduction Agreement:
With this authorization, I am directing my employer to reduce my annual compensation by the premium payments I owe based on my elections. By reducing my annual compensation, I am essentially paying for uncovered benefits and selected benefits plans with pre-tax dollars. I understand that my participation is irrevocable and cannot be changed unless a "Change in Life Status" is experienced, a termination of the Premium, Reduction Plan or one of the benefit plans being offered, or a premium rate adjustment made during the plan year. Additionally, I understand that my election may be renewed for existing coverage as a Plan Participant under this Plan in subsequent Plan Years under the automatic enrollment feature of the Plan. I understand that I and any of my dependents covered for medical(including medical reimbursement) and/or dental benefits will be entitled to certain privacy rules under Federal Law (HIPAA) and that I will receive notifications of those rights upon enrollment. This agreement is subject to the terms of my Employer's Cafeteria Plan, as from time to time in effect, and shall be governed by and construed inn accordance with state and federal laws. This agreement shall take effect as a sealed instrument under such laws and revokes any prior election and compensation reduction agreement.

PAGE 2

-----------------
DEPENDENT INFORMATION
-----------------
* indicates REQUIRED field

Dependent #1
Name (Last, First)*:
Relation*:
SSN*:
DOB*:
Sex*:
___ Medical ___Dental ___Vision ___Vol Dependent Life

Dependent #2
Name (Last, First)*:
Relation*:
SSN*:
DOB*:
Sex*:
___ Medical ___Dental ___Vision ___Vol Dependent Life

Dependent #3
Name (Last, First)*:
Relation*:
SSN*:
DOB*:
Sex*:
___ Medical ___Dental ___Vision ___Vol Dependent Life

Dependent #4
Name (Last, First)*:
Relation*:
SSN*:
DOB*:
Sex*:
___ Medical ___Dental ___Vision ___Vol Dependent Life

-----------------
BENEFICIARY INFORMATION
-----------------
* indicates REQUIRED field

PRIMARY Beneficiaries

PRIMARY Beneficiary #1
Name*:
Relation*:
Phone*:
Percentage*:

PRIMARY Beneficiary #2
Name*:
Relation*:
Phone*:
Percentage*:

PRIMARY Beneficiary #3
Name*:
Relation*:
Phone*:
Percentage*:

PRIMARY Beneficiary #4
Name*:
Relation*:
Phone*:
Percentage*:

CONTINGENT Beneficiaries

CONTINGENT Beneficiary #1
Name*:
Relation*:
Phone*:
Percentage*:

CONTINGENT Beneficiary #2
Name*:
Relation*:
Phone*:
Percentage*:

CONTINGENT Beneficiary #3
Name*:
Relation*:
Phone*:
Percentage*:

CONTINGENT Beneficiary #4
Name*:
Relation*:
Phone*:
Percentage*:

Premium Only IRS Code Section 125

I understand that:
- I cannot change or revoke any of my elections or this compensation redirection agreement at any time during the year unless I have changes in family status (including marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of employment of spouse, changes in my spouse's employment status from full-time to part-time or from part-time to employer covered health coverage, etc...). Notification of change must be within 30 days of the qualifying event.
- Prior to the first day of each plan year, I will be offered the opportunity to change my benefit elections for the following plan year.
- I hereby authorize my employer to reduce my cash compensation by the amount(s) indicated for each pay period during the plan year following the date on which this agreement is signed
- My election may impact my future Social Security benefits.

I have read and understand this agreement and, to the best of my knowledge, acknowledge it to be true, correct and complete.

SIGNATURE:__________________________________________ Date:_________________________________________________________