Revised 3/15/2019 Page | 2
Section C - Payroll Authorization
1. I understand that my employer or plan sponsor, in accordance with the underwriting guidelines of the carrier, will
determine the effective date and termination date of my benefits.
3. I understand that my employee contributions for the benefits I elect are payroll deducted. I authorize the deductions
from my paycheck for any benefits plans in which I enroll and understand that the University will deduct any
retroactive contributions, as needed.
4. I understand that I am responsible for any benefit deductions. If deductions are not collected through payroll because I
did not receive a paycheck, I understand that I must coordinate such payment(s) with the Department of Human
5. I have the option of changing my elections only during the University’s annual open enrollment or within 30 days of a
documented qualified family status change.
6. I am in receipt of information on voluntary benefits.
7. I understand that eligibility to enroll at a later date shall be at the start of each new semester upon verification of
eligible contact hours.
8. I understand that my payroll deductions for benefit elections are pre-tax, where applicable.
By initialing here, __________, I request to have the applicable benefit deductions post-taxed.
9. I understand that if I elect to cover a domestic partner, certain premiums may not be pre-tax and that the University
portion of the premium may be considered taxable income.
By signing below, I certify that I have read and understand the above statements and that all information is true and
correct to the best of my knowledge.
Employee Signature Date
For Human Resources Use Only: Contact Hours: 6 8 9
Basic Life Insurance / AD&D:
Optional Life - Employee:
Optional AD&D - Employee: