Employee Premium Program Agreement

EMPLOYEE PREMIUM PROGRAM AGREEMENT

Parties

This Employee Premium Program Agreement (the "Agreement") is entered into between Employer Name: and Employee Name: . The Effective Date of this Agreement is .

Personal Information

Position Information

Employment Start Date:   Salary/Rate: $

Full-time    Part-time    Temporary/Other

Employment History

Title:   From:   To:

Title:   From:   To:

Education

Major/Field:   Graduation Date:

References

Program Terms and Conditions

Program Description: Employer agrees to contribute toward the cost of premiums for eligible benefit plans selected by Employee under the Employer's benefit offerings (the "Program"). Eligibility is limited to employees who meet the criteria in Section 1. Employee elects the following plan(s) and coverage tier(s):

Plan Selection (check all that apply):
Medical Plan    Dental Plan    Vision Plan    Life Insurance

Employer Contribution: Employer will contribute of the employee premium up to a maximum monthly amount of $ . Employee's estimated share of premium is $ per month.

Payroll Deduction Authorization: Employee authorizes Employer to withhold Employee's share of premium, plus any unpaid premium amounts, from Employee's wages. Payroll deductions will commence on .

Pre-tax/Post-tax Election: Pre-tax    Post-tax. Employee acknowledges tax treatment of contributions may affect net pay and benefits.

Duration, Termination, and Repayment

This Agreement remains in effect while Employee remains employed and enrolled in the Program. Employer may amend or terminate the Program in its sole discretion with prior written notice to Employee as required by applicable law. If Employee ceases employment for any reason within months of an Employer-paid premium contribution, Employee agrees to reimburse Employer the unearned portion of Employer contributions calculated on a prorated basis. Reimbursement may be collected via payroll deduction to the extent permitted by law.

Privacy, Confidentiality, and Data Use

Employee authorizes the use and disclosure of necessary personal information to administer the Program, including enrollment and premium payment. Employer will handle benefit-related personal data in accordance with Employer's privacy practices and applicable law. Medical records are protected and will not be used for employment decisions.

Legal Notices and Disclosures

At-Will Employment: Nothing in this Agreement alters the at-will nature of Employee's employment, unless expressly stated in a separate written employment agreement signed by authorized representatives of Employer and Employee.

Equal Employment Opportunity: Employer is an equal opportunity employer. Eligibility for the Program will be applied in a nondiscriminatory manner.

Authorizations and Certifications

Background Check and References: By signing below, Employee certifies the information provided in this Agreement is true and complete. Employee consents to Employer contacting prior employers and listed references and authorizes Employer to obtain background checks, criminal history, and employment verification as reasonably necessary to verify eligibility and enrollment particulars.

I consent to reference checks and background checks.

Repayment Acknowledgement: Employee acknowledges that repayment obligations described in this Agreement are enforceable to the extent permitted by law and that Employer may recover amounts owed through payroll deduction, offset against final wages, or other lawful means.

Amendment; Governing Law; Dispute Resolution

Employer reserves the right to amend the Program or this Agreement. Any amendment will be effective upon written notice to Employee. This Agreement is governed by the laws of the state where Employer maintains its principal place of business, without regard to conflict of law principles. Except where injunctive relief is sought, disputes arising under this Agreement will be resolved by binding arbitration if mutually agreed or otherwise in the appropriate state or federal court.

Acknowledgement and Applicant Certification

I certify that all information provided in this Agreement is true, complete and accurate to the best of my knowledge. I understand that any false statement or omission may be grounds for denial of program benefits or disciplinary action up to and including termination. I acknowledge I have read and understand the terms of this Agreement and agree to be bound by them.

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