CITY OF BROCKTON

Department of Human Resources

Pre-Tax Premium Payment Plan Election Form

The City of Brockton has adopted a Pre-Tax Health/Dental Insurance Plan to save you money on your insurance premiums. Under this plan, if you have Health/Dental Insurance through the City of Brockton, your premiums can be deducted from your salary on a Pre-Tax basis. Your premiums can be deducted before federal or state taxes or retirement deductions are withheld. This means that you will not have to pay state or federal income taxes on your share of the costs of Health/Dental insurance premiums, which result in a slightly larger paycheck. This will not affect the amount deducted on your current insurance benefits; coverage will remain the same.

Please fill out all required fields accurately and read carefully.

Click the link below to fill out the form 
Pre-Tax Premium Payment Plan Election Form