Fillable Health Plan Deduction from Benefit Check (The United Methodist Church Michigan Conference)

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Health Plan Deduction from Benefit Check (The United Methodist Church Michigan Conference)

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Health Plan Deduction from Benefit Check
Check the applicable box:
q HealthFlexprogramcontribuondeducon q Non-HealthFlexcontribuonorpremiumdeducons
Part 1 – Parcipant Informaon
Parcipantname Parcipant#
Plansponsor SocialSecurity#
qInial deducon
Amounttobedeductedpermonth:$Eecvedate
TheamountindicatedabovewillbedeductedfromthebenetcheckIreceivefromoneormoreofthefollowingplans:
RerementPlanforGeneralAgencies(RPGA),ClergyRerementSecurityProgram(CRSP)[includingtheMinisterial
PensionPlan(MPP)andPre-82Plan],UnitedMethodistPersonalInvestmentPlan(UMPIP),ComprehensiveProtecon
Plan(CPP)and/orBasicProteconPlan(BPP).
q Change in deducon
From:$to$Eecvedate
ThenewamountwillbedeductedfromthebenetcheckIreceivefromoneormoreofthefollowingplans:RPGA,CRSP,
UMPIP,CPPand/orBPP.
Comments:
Note: Whenadeathoccurs,deduconsareautomacallystoppedandwillnotbetransferredtothesurvivingspouse’srecord.Aneweleconformfor
thesurvivingspousemustbereceivedbyWespathBenetsandInvestments(Wespath)totransferbenets.
Part 2 – Authorizaon and Release Signatures
IauthorizeWespathtodeducttheamount(s)IhaveelectedinPart1andapplythededuconstowardpaymentof
myrequiredcontribuonsorhealthinsurancepremiums(contribuons)underthetermsoftheapplicablegrouphealth
plan,eitherHealthFlexor,asagreeduponbetweenWespathandannualconference,thehealthplanmaintainedbythe
annualconference.IalsoauthorizeWespathtomakechangestothesededuconsbasedonanychangesincontribuon
amountduetoeleconchangesorotherwise.IacknowledgethatIamagreeingtoreleaseWespath,itsconstuent
corporations,directors,officers,attorneysandemployeesfromliabilitytome,myspouse,myalternatepayee,
myheirs,namedbeneciaries,orsuccessorsininterest,foranydamageswhichresultfromanyaconoromissiontaken
inrelianceonthisinstrument.
Parcipantsignature Date
Plansponsorsignature Date
Planadministratorsignature Date
3030/081413
PleasemailthiscompletedformtoWespathBenetsandInvestments,DistribuonsTeam,
1901ChestnutAvenue,Glenview,Illinois60025.Besuretokeepacopyforyourrecords.
OryoumayfaxittotheDistribuonsTeamat1-847-866-2736.
1901ChestnutAvenue
Glenview,Illinois60025-1604
1-800-851-2201
wespath.org
a general agency of The United Methodist Church
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Health Plan Deduction from Benefit Check (The United Methodist Church Michigan Conference)

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Completed 23 August 2021

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