Revised 01/09/2019 Page | 2
Section D - Payroll Authorization
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 benefit coverage.
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 deduc
t 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
qualified family status change.
6. I am in receipt of information on voluntary benefits.
7. By opting out of medical and/or dental coverage, I attest that myself and any dependent I claim on my taxes have group
medical and/or dental coverage. I understand that group medical coverage does not include coverage through the
marketplace (also known as the Exchange) or coverage directly from an insurance company. I accept responsibility for
myself and my dependents’ medical and/or dental insurance, including confirming that the other coverage is minimal
essential coverage as defined by the Affordable Health Care Act.
I also understand that in making this election, my employer is not responsible for any lapse in insurance coverage
through my spouse or other entity. Eligibility to enroll later shall be at the University’s annual open enrollment or within
30 days of a qualified family status change.
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.
y 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.
For Human Resources Use Only:
Basic Life Insurance / AD&D:
Long / Short Term Disability:
Optional Life - Employee:
Optional AD&D - Employee: