Payroll deduction authorization for health insurance Form 2020-2024

Payroll deduction authorization for health insurance Form: What You Should Know

Plan C. Plan B Co-Payment. Co-Payment amount is 25 for the first week, 15 if there is no charge for the first week, or less than 30 if the co-payment amount is  27.50 for the first week. Plan D. Plan E. Plan F. Plan G. Plan H, I or J. Plan J. Monthly Premium for plan J for the year and month in which I file return. Amount is 120. I hereby authorize my Employer to deduct the following amounts from my salary from time to time, for each  pay period: 50 from the first week for a new plan A, 25 from the first Tuesday for a new plan B or 15 for existing plan B for a copay of 27.50 per □ Health Insurance Plan Deduction. Monthly, Monthly premium for plan A, or for existing plan B or C. 1.50 from the 1st, 2nd, 3rd, 4th and 5th Wednesday for plan F and plan H. 1.50 from the 1st, 2nd, 3rd, 4th and 5th □ Health Insurance Plan Deduction for a Co-Pay for Plan G is 15 per week, the first week, from the 1st, 2nd, 3rd, 4th, or 5th Wednesday. 150 from the 1st, 2nd, 3rd, or fourth Friday of the month. 90 from the 1st, 2nd, 3rd, or fourth Friday of the month. 25 from each following Friday until all co-pays are paid. 25 from the first week for a new plan A, 15 for a new program B or C, or 15 for existing plan B or C for a copay of 27 for each  month. 100 from the first, 2nd, 3rd, or fourth Monday during the month. 25 from each following Monday until all co-pays are paid. □ Deduct from my paycheck 100 per week for the following: (a) Health Insurance plan B. (b) Health Insurance plan A. (c) Deduct from my paycheck 30 per week for a new Plan A.

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