Section 125 Cafeteria Plan

Section 125 Cafeteria Plan - Election Form

Plan Year: December 1, 2025 - November 30, 2026

Instructions: Select your desired coverage options below. Important: Premium costs are based on age and gender, so your specific monthly cost and per-paycheck deduction will be calculated individually by HR after you submit this form. HR will provide you with your exact costs before payroll deductions begin.

Employer Contribution: Vitatech pays 50% of all insurance premiums. You pay the remaining 50% through pre-tax payroll deductions over 26 paychecks per year.

EMPLOYEE INFORMATION

First Name*

Last Name*

Employee ID

Last 4 Digits of SSN*

Hire Date

Department

BENEFIT ELECTIONS

Select the benefits and coverage levels you wish to enroll in. Vitatech pays 50% of all premiums. Since premiums are based on age and gender, your specific cost will be calculated by HR and communicated to you individually before deductions begin.

Health Insurance Premiums

Vision Insurance Premiums

I am not enrolling in company health or vision insurance at this time

Check this box only if you are waiving coverage entirely (for example, you are covered under a spouse's plan). If you enroll in company insurance, you must participate in the Section 125 Plan and premiums will be deducted pre-tax.

EMPLOYEE ACKNOWLEDGMENT AND AGREEMENT

I understand and acknowledge the following:

My elections under this Section 125 Cafeteria Plan are irrevocable for the Plan Year (December 1, 2025 - November 30, 2026) except as permitted by IRS regulations for qualifying Change in Status events.
My salary will be reduced on a pre-tax basis to pay for the benefits I have elected. The specific per-paycheck deduction amounts will be calculated by HR based on the insurance carrier's age/gender rated premiums and communicated to me in writing before deductions begin.
These salary reductions will reduce my taxable income for federal income tax, Social Security, Medicare, and applicable state income tax purposes.
Reduced taxable income may affect my Social Security benefits, though the impact is typically minimal.
I may only change or revoke my elections during the Plan Year if I experience a qualifying Change in Status event (such as marriage, divorce, birth/adoption of a child, change in employment status, etc.) and the change is consistent with that event.
I have received or been offered the Summary Plan Description for the Section 125 Cafeteria Plan.
I am responsible for ensuring that my benefit elections are appropriate for my personal situation.
If I do not complete this form by the deadline, I will be deemed to have waived health and vision insurance coverage for the Plan Year.

I have read and understand the above statements and agree to participate in the Section 125 Cafeteria Plan as indicated by my elections above.

SIGNATURES

Employee Signature*

Sign and date after printing

Date*

For HR Use Only:

HR Representative Signature

Date Received

Submission Instructions:

Complete all required fields marked with *
Select your desired insurance plan and coverage level for health insurance
Select whether you want vision insurance and the coverage level
HR will calculate your exact per-paycheck deductions based on the carrier's age/gender rates and provide them to you in writing before deductions begin
Print this form, sign and date it
Submit to Human Resources by the enrollment deadline
Keep a copy for your records

VITATECH ELECTROMAGNETICS LLC

Election/Salary Reduction Agreement