Middle Georgia State University Benefits Election Form printable pdf download

Middle Georgia State University Benefits Election Form

IDDLE

EORGIA

TATE

NIVERSITY

Department of Human Resources

100 University Parkway

Macon, GA 31206

Telephone: (478) 471-2010

I, ______________________________, am a new employee of Middle Georgia State University.

(Name)

My date of hire is _____________________________.

(Date)

I have been informed that it is my responsibility to select benefits and name beneficiaries on the

ADP Portal. I understand that I have 30 days from my date of hire to enroll in Middle Georgia

State University’s optional benefits (ex: health insurance, dental insurance, vision insurance, etc.)

If elections are not made, I will not be eligible for benefits until the next Open Enrollment Period.

If I fail to enroll within the first 30 days, I may have to wait as much as one year before I could be

eligible for any optional benefits.

If I wish to cover my spouse or dependents, I will be required to provide documentation as to proof

of relationship (ex: marriage certificate, birth certificate, etc.) for coverage to be approved.

Other than Open Enrollment, the only other time Federal Law allows me to make a change to my

coverage is if I experience a qualifying event (ex: marriage, divorce, death of covered dependent,

birth or adoption of a child, employment or termination of employment of a spouse). Failure to

complete the change within 30 days of a qualifying event will prohibit me from making such

changes until the next Open Enrollment period.

As authorized by Section 125 of the Internal Revenue Code, health and dental deductions are made

before taxes are withheld thus increasing take-hope pay and reducing taxable income.

_________________________

____________________________________

Date

Signature of Employee

Middle Georgia State University Benefits Election Form