ACKNOWLEDGEMENT OF COVERAGE
I authorize Village Ford to make payroll deductions based on the coverage election(s) indicated above. I understand that all of the foregoing elections will be made post-tax in accordance with my plan elections for the 2018 plan year. I further understand that if the required contributions for the elected benefit(s) change while this agreement is in effect, my payroll deductions may be automatically adjusted to reflect the change. I will receive notice of such a change.
I understand that the above election(s) are irrevocable until the next open enrollment period, unless I have a change in family status. A change in family status will include the following: a) marriage or legal separation/divorce/death, b) spouse terminating or obtaining employment, c) transfer to a different employment status (full-time to part-time or vice versa), d) significant change in spouse’s health coverage, and e) loss of dependent status or birth or adoption of a child.
Only benefit changes consistent with the above will be permitted and must be made within 30 days of the change in family status. I understand that I am responsible for notifying Village Ford of any change in family status and for completing the necessary forms within those 30 days.
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