Pre-Tax Premium Payment Plan Election Form You must read the below before completing this form If you wish to have the amount of your Health/Dental premiums deducted from your pre-tax salary please complete Part I of this form. If you do not wish to have your Health/Dental premiums deduction from your pre-tax salary, complete Part II.Department or School(Required) Title (if School Dept.) Name(Required) Last four digits of Social Security Number(Required) PLANS ENROLLED Blue Cross Blue Shield Network Blue Harvard Pilgrim ChoiceNet HMO Blue Cross Blue Shield Blue Care Elect Blue Cross Blue Shield Dental Blue Freedom Part I I authorize the City of Brockton to deduct each pay period an amount equal to the Health/Dental care program premium required for my coverage for that pay period. I understand that amount will be deducted from my pay on a pre-tax basis. The amount of this the premium required, established by the City of Brockton from time to time, is set forth on a schedule, which has been provided to me.Date MM slash DD slash YYYY Signature Part II I do not wish to participate in the Pre-Tax payment plan at this time. I understand that as a result of this election not to participate in the plan, I will not receive an increase in “take home pay”.Date MM slash DD slash YYYY Signature Pre-Tax Health/Dental Insurance Plan 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. The Internal Revenue Service requires that under the Pre-Tax Premium Payment Plan you can change your Health/Dental plan deductions once a year during the annual open enrollment. Whichever election you choose, you may not change your mind until the annual open enrollment period, or unless one of the following occurs: You get married The birth or adoption of a child Your spouse or dependent dies Your spouse commences or is terminated from your employment You or your spouse take an unpaid leave of absence You involuntarily lose Health/Dental insurance through no fault on your own. CAPTCHA
