822814 - Cafeteria Form

Name*

First Last
2016 Cafeteria Form
Please make your selection for each benefit below. All rates are per pay period. Benefit premiums are deducted twice per month. When there are three pay dates in a month, deductions will only be taken for two of them.
Medical - UHC Choice Plus POS HRA

Pre-tax
Medical Plan Summary of Benefits
Health Insurance Premium*
Dental - Guardian PPO

Pre-tax
"Low Plan" Features

"High Plan" Features
Dental Insurance Premium*
Vision - Avesis

Pre-tax
Vision Plan Features
Vision Insurance Premium*
Flexible-Spending Accounts - 125Company
Flexible Spending Accounts allow you to use pre-tax dollars to pay for many healthcare expenses (for you and/or your spouse/dependents) that aren't covered by your health insurance, as well as dependent care expenses. Click on the links in the following two sections to view detailed lists of eligible expenses for each category.

Click on the "Flexible-Spending Calculator" link for a helpful tool that will recommend what your FSA contribution should be, as well as your estimated tax savings.

It is important to be conservative in making elections because any unused funds left in your FSA are not refundable to you.
Number of Pay Dates With Benefit Deductions Remaining In The Year
Healthcare FSA

Pre-Tax
Flexible-Spending Calculator

Eligible Healthcare Expenses
Healthcare FSA*

I do not want to contribute to this FSAI would like to contribute to this FSA
Annual Healthcare Election (if completing this form mid-year, election amount is for the remainder of the current calendar year)
Maximum $2550
Converted Value - HealthCareFSA
Maximum Health Care Election Exceeded
Per-Pay Healthcare FSA Deduction Amount
Dependent Care FSA

Pre-tax
Dependent Care Overview and List of Qualifying Expenses
Dependent Care FSA*

I do not want to contribute to this FSAI would like to contribute to this FSA
Annual Dependent Care Election (if completing this form mid-year, election amount is for the remainder of the current calendar year)
Maximum $5000
Converted value- dependent care election
Maximum Dep Care Election Exceeded
Per-Pay Dependent Care FSA Deduction Amount
Voluntary Life / AD&D Insurance - Guardian

Post-tax
System Automation provides full-time employees with $20,000 of group life and accidental death and dismemberment (AD&D) insurance, and pays the full cost of this benefit. Employees may purchase additional coverage for themselves and dependents.

SA-Provided Life/AD&D Insurance Policy Summary

Voluntary Life Insurance/AD&D Policy Summary
Employee Coverage
EE Vol. Life*

I do not want this coverageI would like this coverage
Your Age
Desired Coverage Amount - Employee
Desired Coverage Amount Converted- Employee
Coverage Unit Amount - Employee
Employee Vol. Life Coverage Premium - without 2 decimal places
Employee Vol. Life Coverage Premium
Spouse Coverage
SP Vol. Life

I do not want this coverageI would like this coverage
Spouse's Age
Desired Coverage Amount - Spouse
Amount cannot be greater than 50% of the employee's amount
Desired coverage amount converted -spouse
50% of employee's amount
Max Coverage Amount Exceeded for Spousal Coverage
Coverage unit amount - spouse
Spouse Vol. Life Coverage Premium- without 2 decimal places
Spouse Vol. Life Coverage Premium
Dependent(s) Coverage
Dependent Vol. Life

I do not want this coverageI would like this coverage
Desired Coverage Amount - Dependent Child(ren)
Amount cannot be greater than 10% of the employee's amount
Desired coverage amount dependent -converted
10% of employee's amount
Coverage Unit Amount - Dependent Children
Max Coverage Amount Exceeded for Dependent Child(ren) Coverage
Dependent Vol. Life Coverage Premium - without two decimal places
Dependent Vol. Life Insurance Premium
Voluntary Short-Term Disability Insurance - Guardian

Post-tax
Short-Term Disability Coverage Summary
Short-Term Disability*

I do not want this coverageI would like this coverage
Enter Your Annual Salary
Enter Your Age
Weekly benefit calc
Your Weekly Benefit Amount
STD Premium
Voluntary Long-Term Disability Insurance - Guardian

Post-tax
System Automation pays the full cost of your long-term disability benefit (payable up to five years for disabilities occuring before age 60). You have the option to purchase additional LTD benefits which will provide income replacement until your full ("normal") Social Security retirement age.

Long-Term Disability Insurance Summary of Benefits
Long-Term Disability*

I do not want this coverageI would like this coverage
Enter Your Annual Salary
Monthly benefit amount calc
Your monthly benefit amount
LTD Premium
Total Deductions
Total Semi-Monthly Payroll Deduction Amount
Total deduction does not include 401(k) deferral amounts or AFLAC premiums
Consent
By signing below, I authorize System Automation to make the above payroll deduction(s) to pay the employee portion of the benefit(s) I have chosen. I understand that I am making a binding election(s) with respect to my benefits under System Automation's cafeteria plan which cannot be changed until the anniversary date of the plan, unless there is a change in my family circumstances.*

Clear
If you wish to print your form, please do so before you submit it.
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2016 Cafeteria Form

Medical - UHC Choice Plus POS HRA

Dental - Guardian PPO

Vision - Avesis

Flexible-Spending Accounts - 125Company

Healthcare FSA

Dependent Care FSA

Voluntary Life / AD&D Insurance - Guardian

Employee Coverage

Spouse Coverage

Dependent(s) Coverage

Voluntary Short-Term Disability Insurance - Guardian

Voluntary Long-Term Disability Insurance - Guardian

Total Deductions

Consent