Fillable Cancellation Miscellaneous Deductions Insurances (University of West Florida)

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Cancellation Miscellaneous Deductions Insurances (University of West Florida)

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UNIVERSITY OF WEST FLORIDA
CANCELLATION FORM
(miscellaneous deductions and insurances which are not pre-taxed)
Insurance Plan Code
Long-term Disability LD1/LD4
Long-term Care (John Hancock) CLT
Post-Tax Life/AD&D Insurance
SD1
Bi-weekly Amount
Miscellaneous Deductions Code Bi-weekly Amount
Emergency Fund EF1
United Way UWE
University Foundation FD1
Other(s)
Name (please print)
UWF ID No. Date
___________________________________
Effective date of cancellation
** Pre-taxed benefits may only be changed due to a qualifying status change event. Pre-tax benefits include: health,
life, dental, hospital supplemental, vision, reimbursement accounts and plans with Colonial Insurance. Changes must
be relevant to the event.
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Cancellation Miscellaneous Deductions Insurances (University of West Florida)

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Completed 19 July 2020

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