I authorize Moore Control Systems, Inc. to deduct the cost of any elected benefits for medical, dental, vision and FSA benefits from my pay on a pre-tax basis, as authorized under the 125 plan. I further authorize Moore Control Systems, Inc. to deduct the cost of any elected benefits for life and disability benefits on an after-tax basis. I declare that all entries on this form are true and complete and that any material misstatements or failure to report information may be used as the basis for cancellation of coverage for me and my dependent(s) (if any) from the original effective date of coverage. If I am not actively at work or are unable to engage in all the usual duties of a person of like age and sex, the effective date of all non-medical coverage will be delayed until I return to work and resume usual duties. A photographic copy of this authorization shall be valid as the original.
I understand that elections (including elections not to participate) will continue for the entire plan year unless there is a change event as described in the 125 plan such as the formation of a new dependent relationship as a result of marriage, birth, or adoption or the dissolution of a relationship such as divorce, or loss of other coverage, I must request an election change within 31 days after such event.
I understand that my dependent(s) and I may be considered a Late Enrollee(s) subject to a longer preexisting condition exclusion limitation if we don’t enroll when initially eligible.
