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Section 125 election form

SECTION 125 PREMIUM ONLY PLAN Employee Election Form 2026

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The document is an Employee Election Form for the Premium Only Plan under Section 125, which allows employees to pay their insurance premiums with pre-tax dollars, thereby increasing their take-home pay. It outlines key points about the plan, including its impact on taxable income and Social Security benefits, as well as exclusions for certain types of insurance. The form includes sections for employees to elect participation in the plan or report changes in family or employment status that may affect their premium deductions.

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Click ‘Get Form’ to open the SECTION 125 PREMIUM ONLY PLAN Employee Election Form in the editor.
Begin by entering your name and the date at the top of the form. This personal information is essential for processing your election.
Fill in your employer's name in the designated field. This ensures that your election is correctly attributed to your employer.
In the Plan Election Section, choose whether you wish to participate in the Premium Only Plan by checking the appropriate box. If you opt-in, specify your monthly pre-tax deduction amount.
Sign and date the form at the bottom of this section to confirm your election choice.
If applicable, complete the Election Change Section by indicating any changes in family or employment status that affect your premium deductions. Provide a new monthly pre-tax deduction if necessary.
Finally, sign and date this section as well to validate any changes made.

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What is ADP premium only plan?

ADP's Premium Only Plan (POP) helps businesses and employees reduce their tax expenses by allowing employees to pay part of their health insurance premiums with pre-tax dollars. Typical eligible premiums include: Health, Dental, Vision, Disability and Life insurance.

Is a premium only plan the same as a section 125?

The Section 125 program is a tremendous opportunity for you to enhance your benefits package. The Premium Only Plan is the building block of the Section 125 Plan. It allows for certain employee paid group insurance premiums to be paid with pre-tax dollars.

What is Section 125 enrollment form?

Enrollment in the 125 POP allows active employees to reduce their taxable income by withholding certain qualifying benefit premiums BEFORE taxes. When you begin employment in an eligible position you have 30 days to enroll.

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