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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Insurance Plan Code Bi-weekly Amount
Long-term Disability
LD1/LD4
Long-term Care (John Hancock)
CLT
Post-Tax Life/AD&D Insurance
SD1
Other(s)
Name (please print)
Signature
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.
MISCELLANEOUS DE
DUCTIONS AND INSURANCES
CANCELLATION FORM
(Only those which are not pre-taxed may be ended with this form)
Miscellaneous Deductions Code Bi-weekly Amount
Emergency Fund
EF1
United Way
UWE
University Foundation
FD1
________________
________________
________________
_
_______________
________________
________________
________________
_________________________________________ _________________________________________
_________________________________________ _________________________________________
________________________________________
Please return all complet
ed forms to Human Resources, Benefits Section, Building 20E
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Cancellation Miscellaneous Deductions Insurances (University of West Florida)

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Completed 22 July 2020

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