Benefits Payroll Deduction Authorization

This form can be used to authorize new benefit deductions, request changes to current deductions and/or cancel benefit deductions. 

Employee Information – Complete this section in its entirety.

Employee name: ______________________________________________

Social Security number:_________________________________________

Home address: _______________________________________________

City, State, Zip: _______________________________________________

Hire date: ____________________________________________________

Job title and department: ________________________________________

Add Payroll Deductions – Complete this section to authorize payroll deductions.

Benefit type: ___________________________________________________

Level of coverage: ______________________________________________

Biweekly payroll deduction: _______________________________________

Effective date: __________________________________________________

I authorize the above pre-tax salary deductions to be withheld from my bi-weekly pay. I authorize deduction rate increases or changes as required by the benefit provider in accordance with the terms and conditions of my policies.

Pre-tax benefit changes are subject to the mid-year election change rules outlined in the benefit summary plan description.

Employee signature: ________________________           Date: __________

Change Payroll Deductions – Complete this section to authorize to payroll deduction changes.

Benefit type: ___________________________________________________

Level of coverage: ______________________________________________

Reason for the change: _______________________________________

Effective date: __________________________________________________

Pre-tax benefit changes are subject to the mid-year election change rules outlined in the benefit summary plan description.

I authorize the above pre-tax salary deductions to be withheld from my bi-weekly pay. I authorize deduction rate increases or changes as required by the benefit provider in accordance with the terms and conditions of the benefit policies.

Employee signature: ________________________           Date: __________

Cancel Payroll Deductions – Complete this section to stop payroll deductions.

Benefit type: ___________________________________________________

Level of coverage: ______________________________________________

Reason for cancellation: _______________________________________

Effective date: __________________________________________________

Pre-tax benefit changes are subject to the mid-year election change rules outlined in the benefit summary plan description.

I no longer desire to participate in the pre-tax salary deduction program for the above listed benefits. Please cancel the above deductions as of the above effective date.* Deduction cancellation requests must be received eight work days prior to the effective pay date.

Employee signature: ________________________           Date: __________

*Cancellations and changes to payroll deductions will normally be effective the pay period following the date on this form. Retroactive changes are not authorized.