Premium Only Plan
Date Signature Social Security Number
The
college offers to its employees the Premium Only Plan whereby premiums for medical
and vision insurance are deducted from your paycheck before social security or income
taxes are assessed, thereby acting as a tax savings to you. Since Social Security
contributions are reduced by reducing taxable income, funds available for future retirement
or disability benefits may also be lower. To supplement this, employees may elect to
transfer a portion of their tax savings into an interest sensitive savings or investment
program.
IRS regulations require that we have a response from you indicating your desire
concerning participation in this program. Please indicate with a check mark, sign, and
return this form to the Human Resource Services office.
Y
es, I wish to participate in the Clovis Community College Premium Only
Plan the year beginning January 1, following the date of my election
below or my date of hire and continuing until I notify the Human Resource
Services office in writing. I understand that the effective date of such
notification will be January 1 of the following calendar year.
I understand that to participate I must elect to commit an amount out of
my salary equal to the premiums. I understand that I may not change
this amount while this plan is in effect unless an IRS recognized change
in my family status (marriage, divorce, death, or birth of a child) occurs
or unless I notify the Human Resource Services Office prior to the
calendar year that I wish to discontinue the program. I understand that
no part of this amount will ever be available to me, except to pay
premiums for coverage under the Clovis Community College sponsored
insurance program.
No, I do not wish
to participate in Clovis Community College
Premium Only Plan.
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Requires signature.
Deliver completed form to Human
Resource Services.
Please fill out information in spaces provided.
