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PREMIUM ONLY PLAN REQUEST FORM Please complete this form and send it along with payment of $300 payable to: Benefit Advantage, Attn: Finance, P.O. Box 5490, De Père, WI 54115-5490 Name of Organization:

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What is premium only plan request?

The premium only plan request is a form that allows employees to have their health insurance premiums deducted from their wages before taxes are withheld.

Who is required to file premium only plan request?

Employees who wish to participate in a premium only plan are required to file a request with their employer.

How to fill out premium only plan request?

Employees can fill out the premium only plan request form provided by their employer, providing their personal information and selecting the health insurance plan they wish to enroll in.

What is the purpose of premium only plan request?

The purpose of the premium only plan request is to allow employees to pay for their health insurance premiums with pre-tax dollars, saving them money on taxes.

What information must be reported on premium only plan request?

The premium only plan request form typically requires employees to provide their name, address, social security number, and details of the health insurance plan they wish to enroll in.

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