BENEFITS OPT-OUT FORM

BENEFITS OPT-OUT FORM
If you wish to opt out of any employee benefits Accelerated Automation LLC offers, please complete this Benefits Opt-Out Form. Clearly indicate which benefits you are declining and sign at the bottom. Submit the completed form to Meg Brenneman by June 3rd, 2024.
Employee Name
Position
Department
Date

MonthDayYear
Date
Benefits Opt-Out Details

You can check one or both boxes if you choose to opt-out of the offered benefits.
Health Insurance Reimbursements ($300)Retirement Plan (SIMPLE IRA)
Please specify your reason for opting out
I *, voluntarily choose to opt-out of the above-mentioned benefit plans provided by Accelerated Automation LLC. I have read and understand the implications of my decision, and I assume full responsibility for any outcomes as a result of this action. .
Employee Signature
Date

MonthDayYear
Date
Reviewed By
Date Reviewed

MonthDayYear
Date
Comments
Please review this form carefully before submitting it to the Administrative Team. For any questions or clarifications, please contact Mariah Gates.

This Benefits Opt-Out Form is in compliance with company policies and state and federal laws regarding employee benefits.
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