Benefit Election. Please answer the following questions and check the corresponding box to confirm the benefit you are electing (if more than one option is provided). Do you claim that this firearm has fired without a trigger pull, which resulted in personal injuries or property damage? (Note any such claim is not included in or affected by this settlement.) Yes - I want to receive pre-paid shipping tags, boxes, and written instructions on how to return my firearm to Remington for a full inspection as well as an X-Mark Pro retrofit at no cost. This benefit is available now, even if final court approval of this settlement has not been achieved as of the date this Claim Form is submitted. After the retrofit, Xxxxxxxxx will return my firearm to me at no cost. Remington will also send me an educational DVD regarding safe firearm handling practices.
Benefit Election. The Executive elects the Benefit listed below next to which he or she has subscribed his or her initials. If no option is initialed, or if the Executive elects to defer his or her election of a Form of Retirement Benefit but thereafter fails to make a timely election, then the Executive’s Form of Retirement Benefit shall be the Post-Retirement Death Benefit provided for in Section 6(c)(i) of the Plan.
Benefit Election. Check here if this election represents a change from last year’s enrollment. Indicate change here: I understand my share of the current cost for coverage is: Medical coverage (Select One) PPO HDHP $121.80/mo employee-only $111.78/mo employee only $334.89/mo two-person $307.04/mo two-person $408.03/mo family $374.10/mo family Dental coverage (Select One) High Dental Low Dental $36.65/mo employee-only $24.86/mo employee only $71.73/mo two-person $48.05/mo two-person $122.09/mo family $79.35/mo family Vision coverage (employee only is employer paid) Vision $2.04/ mo for two person or family coverage My signature indicates that I require coverage and that my share of the cost shall be contributed on a pretax basis. Signature Date
Benefit Election. SPECIMEN To elect a benefit under this Rider: • You must request payment of the Rider benefit during Your lifetime in a written form; and • You must submit to us written proof that You qualify for the Rider benefit. You may only elect to receive benefits under this Rider once. At our expense, we may require an examination of You by a second Physician to verify any diagnosis or certification made by the initial Physician. The second Physician may be chosen by Us. If You are required by a government agency to use this Rider benefit in order to apply for, obtain, or keep a government benefit or entitlement, then You are not eligible to elect the benefit provided by this Rider. If any Owner dies before We make any payment under the terms of this Rider, We will consider the election to be null and void. We will pay the Beneficiary the Death Benefit as provided in the Contract when We receive due proof of death.
Benefit Election. To elect a benefit under this Rider: • You must request payment of the Rider benefit during Your lifetime in a written form; and • You must submit to us written proof that You qualify for the Rider benefit. You may only elect to receive benefits under this Rider once. At our expense, we may require an examination of You by a second Physician to verify any diagnosis or certification made by the initial Physician. The second Physician may be chosen by Us. If the opinion of the second Physician is different than the opinion of the initial Physician, the opinion of the second Physician will rule. If You are required by a government agency to use this Rider benefit in order to apply for, obtain, or keep a government benefit or entitlement, then You are not eligible to elect the benefit provided by this Rider. If any Owner dies before We make any payment under the terms of this Rider, We will consider the election to be null and void. We will pay the Beneficiary the Death Benefit as provided in the Contract when We receive due proof of death.
Benefit Election. Yes! Please sign me up for continual reimbursement of my orthodontia expense.
Benefit Election. 7. Do you wish to receive a Cash Payment or a Credit Certificate good toward the future purchase of Defendants’ products? □Cash Payment □Credit Certificate Inspection Demand – COMPLETE ONLY IF YOU SELECTED GROUP A IN RESPONSE TO QUESTION 1 ABOVE
Benefit Election. Full-Time Only Full-Time and Part-Time: Effective Date: _ / Plan Number (501, 502, etc): Open Enrollment Period: From: Through: Plan(s) Elected: HDHP/Basic MEC Plan / Advantage Plan / Both Employer Contribution Strategy: Fixed Dollar Amount: / Percentage of Premium: Please place Employer Contribution in plan(s) chosen: HDHP/Basic MEC Plan EE Status Premium Employer Contribution Full-Time Employees Employer Contribution Part-Time Employees EE Only $66.00 $ $ EE + Child(ren) $96.00 $ $ EE + Spouse $96.00 $ $ EE + Family $96.00 $ $ Advantage Plan EE Status Premium Employer Contribution Full-Time Employees Employer Contribution Part-Time Employees EE Only $133.75 $ $ EE + Child(ren) $202.24 $ $ EE + Spouse $218.24 $ $ EE + Family $293.30 $ $ Employee Contributions will be paid by: Payroll Deductions: (Initial)
Benefit Election. Please answer the following questions and check the corresponding box to confirm the benefit you are electing (if more than one option is provided). Do you claim that this firearm has fired without a trigger pull, which resulted in personal injuries or property damage? (Note any such claim is not included in or affected by this settlement.) Yes - I want to receive pre-paid shipping tags, boxes, and written instructions on how to return my firearm to Remington for a full inspection as well as an X-Mark Pro retrofit at no cost. This benefit is available now, even if final court approval of this settlement has not been achieved as of the date this Claim Form is submitted. After the retrofit, Xxxxxxxxx will return my firearm to me at no cost. At a later time, Xxxxxxxxx will also send me an educational DVD regarding safe firearms handling practices. No - (Choose one option below) □ Option 1. I want to take my firearm to a Remington Authorized Repair Center for an X-Mark Pro retrofit at no cost. A list of Remington Authorized Repair Centers can be found by visiting xxx.xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx or calling 1-800- 000-0000. I will receive a Ticket ID# to take to the Remington Authorized Repair Center to have my firearm retrofitted. This benefit is available now, even if final court approval of this settlement has not been achieved as of the date this Claim Form is submitted. At a later time, Xxxxxxxxx will also send me an educational DVD regarding safe firearm handling practices. □ Option 2. I want to receive pre-paid shipping tags, boxes, and written instructions on how to ship my firearm to a Remington Authorized Repair Center for an X-Mark Pro retrofit at no cost. This benefit is available now, even if final court approval of this settlement has not been achieved as of the date this claim form is submitted. After the retrofit, Xxxxxxxxx will return my firearm to me at no cost. At a later time, Xxxxxxxxx will also send me an educational DVD regarding safe firearms handling practices. PLEASE GO TO SECTION 5.
Benefit Election
