IRS Section 125 Premium Only Plan (POP) - Enrollment Form
Enrollment in the 125 POP allows active employees to reduce their taxable income by withholding certain qualifying
benefit premiums BEFORE taxes. When you begin employment in an eligible position you have 30 days to enroll. If you do
not complete and submit this form to the payroll specialist in the council within the 30 days, you will automatically have
your eligible contributions under Section 125 of the Internal Revenue Code deducted AFTER federal income tax and Social
Security are deducted.
Name:
premiums for the coverage(s) which I have elected under the Boy Scouts of America Employee Benefits Program and which
require a personal contribution under the Section 125 Premium Only Plan (POP). I understand that I cannot change any of
my elections unless I have a qualifying change in family status per Section 125 of the Internal Revenue Service Code.
I elect not to participate in the Section 125 Premium Only Plan (POP).
I elect and authorize Boy Scouts of America to make the deductions/reductions from my paycheck necessary to cover the
I understand that my signature below indicates that I have read this form and the other information provided to me concerning
the employee benefit program of the Boy Scouts of America and have made the election above.
I also understand that this election will stay in force until I make another election following a qualifying life event change or during
the annual enrollment period.
Signed By:
Date Signed:
Return to your payroll specialist.
It is not necessary to re-enroll each year.
S. S. No.
