Feedback/ Request Forms : choiceshr.com

All full-time CICL or part-time employees hired before January 1, 2007 are required to complete this form to indicate their choice for how their annual benefit allowance will be utilized.

This form is to be completed even if your selection is to decline participation in all optional benefit coverages. If you select to participate in any of the optional coverages, you will be required to complete the appropriate enrollment form. If this applies to you, please select the appropriate enrollment form from the "Feedback/Request Forms" section at the ChoicesHR.com website.

If you have any questions, or would like to request a hardcopy of the form, contact Human Resources at 937/898-2220.

CICL 2010 Employee Benefit Selection Form

*Your Email Address:

If you do not have an email address to insert in the previous question, please insert the following email address: employee@cicl.com

Full Name:

   * Present Position:

   * Hire Date w/CICL:

   * I would like to participate in the United Healthcare Medical Insurance Plan (Y/N):

   * I would like to participate in the Superior Dental Insurance Plan (Y/N):

   * I would like to participate in the Unum Term Life Insurance Plan (Y/N):

   * I would like to participate in the Chard-Snyder Flexible Spending Account (FSA) Plan (Y/N):

   * I would like to participate in the Unum Long Term Disability Insurance Plan (Y/N):

   * I would like to participate in the American Fidelity Assurance (GAP) Insurance Plan (Y/N):

   * I would like to participate in the "Cash Out" Option at the 50% rate. (Based upon availabilty of benefit allowance) Y/N:

   * I would like to participate in the Investment Saving Plan (Y/N):

   *

Employee Electronic Signature:

I certify that all statements are true to the best of my knowledge and belief and I understand that a copy of this form will be made available to me at my request. I authorize CICL to make the necessary deductions from my compensation to pay the premium when my insurance becomes effective, if appropriate. I undertstand that my payroll deduction amount will change if my coveage or costs change.

My employee number and the last four digits of my SS# are: (111111/2222)