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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your personal information in the designated fields, including your name and Social Security Number. Ensure accuracy as this information is crucial for tax processing.
- Next, indicate your election to participate in the Premium Only Plan by checking the appropriate box. This decision affects how your premium payments are taxed.
- Complete the Employee Enrollment Information section. Fill in the enrollment date and first check date, along with deduction frequency based on your pay periods.
- For each benefit type (Health, Dental, Life, Other), input the per-pay-period amount and number of pay periods to calculate your annual premium. Double-check these calculations for accuracy.
- Finally, sign and date the form at the bottom to validate your enrollment or waiver choice before submitting it through our platform.
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APPEARANCES: For the Government: JOSEPH NOCELLA, JR. Interim United States Attorney. BY: KAITLIN T. FARRELL. KAYLA C. BENSING. NINA C. GUPTA. SEAN M. FERN.