PENSION CHECK DEDUCTION AUTHORIZATION
I, the undersigned, am receiving a monthly benefit from the Michigan U.P. IBEW Pension Fund and am also maintaining my eligibility for benefits under the Michigan Electrical Employees Health Plan by means of self-payments for the RETIREE PLAN.
As a convenience to me, I hereby request and authorize you to deduct from my monthly Pension Fund benefit whatever amounts may be required from time to time to maintain my HEALTH coverage for myself and my spouse in the RETIREE PLAN as reported to you by the Health Plan and/or my coverage in the SUPPLEMENT MEDICARE PLAN, as reported to you by the Health Plan and to remit such deducted amounts directly to the Health Plan.
I understand that I may revoke this authorization at any time by written notice to the Health Plan at 6011 West St. Joseph, Suite 401, Lansing, MI 48917 and the U.P. IBEW Pension Plan at 130 W. Washington St., Suite L 9, Marquette, MI 49855, but also understand that at least 60 days advance notice to do so is required.
NAME________________________________ SIGNATURE _____________________
SS#_______________________ DATE ___________________________
EXPLANATION
This Assignment and Authorization Request Form is designed to serve as a convenience to you. Authorizing deductions of self-payments from monthly Pension benefits, while purely voluntary, will eliminate the inconvenience and expense of writing and mailing checks or money orders to the Health Plan Office each month. More importantly, this will eliminate the risk of losing coverage due to illness, travel, delay in the mail, or other circumstances which would prevent you from remitting your self-payment within the prescribed time. The amount deducted cannot, of course, be more than your monthly benefit from the Pension Fund.
If there are any changes in the rate for your self-payment, you will be notified in advance and will be able to revoke your authorization for deductions if you choose to end coverage under the Health Plan.
The first deduction from your Pension check will be for the following month.
EXAMPLE:
The Pension Plan deducts monies from your Pension check in the month of June. This deduction will pay your Retiree payments for the month of July.
This enables the Health Plan to receive the payment from the Pension Fund and process the payment to give you eligibility.