Follow the steps to complete the form accurately online.

1. Click ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Begin by filling in your name and the date at the top of the form. This information identifies you as the employee making the election.
3. Enter your employer's name in the designated field. It's important to provide accurate employer information, as it links your election to the correct company.
4. In the Plan Election Section, carefully read the options provided. You can choose to participate in the Premium Only Plan or opt-out. Indicate your choice by marking the appropriate box.
5. If you choose to participate, enter the amount for your Monthly Pre-tax Deduction in the specified field. Ensure accuracy, as this amount will affect your take-home pay.
6. Sign your name and include the date at the end of the Plan Election Section. This signature confirms your understanding and agreement to the terms stated.
7. If applicable, move to the Election Change Section. Here, indicate any changes in your family or employment status that justify a change in your premium deductions.
8. Mark the relevant checkbox for your status change and provide the new Monthly Pre-tax Deduction amount along with the date of the status change.
9. Lastly, sign and date the Election Change Section if you’ve made any updates. Ensure all information is clear and legible.
10. Once all sections are completed, save your changes. You may download, print, or share the form as needed.

Complete your SECTION 125 PREMIUM ONLY PLAN Employee Election Form online today to maximize your benefits.