Forms
The following forms may be useful to assist you with the
administration of your plan.
CAUTION: not every form fits every Plan. We recommend that you
contact your administrator to receive instructions on which forms are
most appropriate for your situation. In some cases, none of the
following forms will be appropriate and a more customized form will be
necessary.
Please note that these forms have "Fill in the Blank" Features.
In order to read the following forms you must have Adobe Acrobat
Reader. If you do not already have this program on your computer, you
can go to the website and download it now. Click on the logo or the
following link:
Acrobat
401(k) Salary Deferral Enrollment Application
This is a generic enrollment application for a 401(k) Plan. It
makes no reference to the plan name. If your plan has specific
investment elections that need to be made, this may not be the
appropriate form.
Form: Generic 401(k) Enrollment
Participant Loan Application
Many Plans allow participants and beneficiaries to borrow from
the plan. Not all Plans allow loans. First check to see if your plan
even allows for loans. There are also many rules about how much can
be loaned, what interest rate is applicable, and when the loan must
be paid back. These rules will be specific to each plan and will be
contained in the Participant Loan Policy. The following is a generic
Loan Application.
Form: Loan Application
Rollovers from Outside Plans
Most Plans will allow a participant to roll over benefits and
balances that have been accumulated in previous employer's plan.
However, not all plans accept rollovers. The following form is a
generic explanation in regard to rollovers:
Form: Rollovers
Notice of Termination
When an employee terminates employment, he or she may be eligible
for immediate distribution. The rules for the timing of the
distribution can be different for each plan and should be explained
in the Summary Plan Description. In any case, the administrator will
need written verification that an employee has terminated
employment. The following is a generic form that can be used to
inform your administrator at Primark Benefits about an employee's
termination of employment.
Form: Notice of Termination
Cafeteria Plan Claim Form
Use this form to submit requests for reimbursement and receipts
for all cafeteria Plan Claims:
- Uninsured Medical/Dental/Vision Expenses
- Health Insurance Premium Expenses
- Dependent Care Expenses
Form: Cafeteria Plan Benefits Claim
Form
Compensation Reduction Agreement - Medical
Reimbursement
Use this form to elect to have your paycheck reduced by a
specific amount each pay period. These funds will be put "on
reserve" for the reimbursement of uninsured medical expenses.
Form: Election for Medical
Reimbursment Plan Benefits
Compensation Reduction Agreement - Premium
Conversion
Use this form to elect to covert your share of the premium for
the employer sponsored health care insurance premium into a
"pre-tax" payment.
Form: Election for Premium
Conversion Plan Benefits
Compensation Reduction Agreement -
Dependent Care
Use this form to elect to have your paycheck reduced by a
specific amount each pay period. These funds will be used to cover
dependent care expenses.
Form: Election for Dependent
Care Plan Benefits
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