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Get UMass HIRD Form For Non-Benefited Employees 2007-2024

Iddle Initial: Employee Last Name: Suffix (e.g., Sr., Jr.): Employee Social Security or Tax Identification Number: Please check the appropriate box for each question: 1. Were you offered employer subsidized health insurance? Yes 1a. If Yes, did you decline your employer subsidized health insurance? 2. Were you offered a Section 125 Cafeteria Plan to pay for health insurance? The S125 Plan allows you to request that the premium for your health insurance through the Commonwealth Connect.

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