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Allegiance FLEXIBLE BENEFITS ENROLLMENT FORMBenefit Plan ManagementPlease print clearly EMPLOYER:DIVISION:City of Missoula SSN:OPEN ENROLLMENT: EFFECTIVE DATE (mm/dd/by):NAME:BIRTH DATE (mm/dd/YYY):MAILING

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How to fill out premium only enrollment form

01

Obtain a premium only enrollment form from your employer or benefits administrator.

02

Fill out your personal information including your name, address, and social security number.

03

Choose the amount you would like to contribute to your premium only plan each month.

04

Sign and date the form to indicate your agreement to participate in the premium only plan.

05

Return the completed form to your employer or benefits administrator for processing.

Who needs premium only enrollment form?

01

Employees who want to contribute to their health insurance premiums on a pre-tax basis.

02

Employers who offer premium only plans as a benefit option for their employees.

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What is premium only enrollment form?

Premium only enrollment form is a document that allows employees to elect to have their portion of health insurance premiums deducted on a pre-tax basis.

Who is required to file premium only enrollment form?

All employees who wish to have their health insurance premiums deducted on a pre-tax basis are required to file a premium only enrollment form.

How to fill out premium only enrollment form?

Employees can fill out the premium only enrollment form by providing their personal information, choosing their desired health insurance plan, and indicating their election for pre-tax deductions.

What is the purpose of premium only enrollment form?

The purpose of the premium only enrollment form is to allow employees to save money on their health insurance premiums by deducting them on a pre-tax basis.

What information must be reported on premium only enrollment form?

The premium only enrollment form typically requires employees to report their personal information, desired health insurance plan, and election for pre-tax deductions.

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