CNM PRE-TAX PREMIUM PLAN
Plan Year: January 1, 20xx - December 31, 20xx

In accordance with IRS regulations governing CNM’s Section 125 Plan, each employee is given the opportunity to make appropriate changes to his/her Spending Account deductions and Pre-Tax Premium Plan to suit her/his individual needs.

If you are currently enrolled in the Pre-tax Premium Plan for 20XX you do not need to re-enroll for the Plan Year 20xx, you will automatically be enrolled (this applies ONLY to the Pre-Tax plan enrollment). To discontinue the Pre-Tax plan, however, you must indicate you wish to do so below.

Please check Option(s)

______  YES, I will accept the opportunity to enroll in the CNM Pre-Tax Premium Plan.  I hereby authorize CNM to deduct my insurance premiums from my salary each pay period on a pre-tax basis for the insurance coverages I have elected.

          ______ I do not wish to participate in the CNM Pre-Tax Premium Plan for 20xx.

All participants are strongly advised to plan carefully.  The Internal Revenue Service (IRS) rule requires participation for the full plan year.

I authorize CNM to withhold my Pre-Tax Contribution selected on this form. I also understand that I cannot change this option for the remainder of the plan year, unless my family status changes.                                          

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Employee Signature                                                                                   Please Print Name              

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Employee Social Security Number                                                      Date