EMPLOYER ENROLLMENT FORM OPT-IN EFF 7-1-2016.PDF

CORRECTIONS OFFICER RETIREMENT PLAN
CANCER INSURANCE PROGRAM
EMPLOYER ENROLLMENT FORM
PO BOX 17323 PHOENIX, AZ 85011-0323 TEL (602)255-5575 FAX (602)296-2371
Employer Information
Employer Name
Address City State Zip Code
Contact Name Contact Telephone Contact E-mail
Cancer Insurance Program
The Cancer Insurance Program is being extended as a voluntary program to employers pursuant
to A.R.S. §§ 38-641-645. This form must be received by PSPRS no later than June 15, 2016.
Our agency wishes to offer the Cancer Insurance Program to our eligible employees and we agree to
the Employer Terms of the Plan included below:
1. We will introduce and offer the Plan to our eligible employees.
2. We will submit Employee Enrollment Forms for participating employees to PSPRS per the Terms of the Plan.
3. We will maintain eligibility and premium payment records of the Plan for our enrolled employees.
4. We will collect the $50.00 annual premium from the enrolled member paycheck and submit those monies
to PSPRS no later than August 31, 2016 for employees effective July 1, 2016.
5. We understand that the earliest effective date for employees is July 1, 2016 since our agency is opting in
after the initial enrollment period.
6. We will offer this plan to our new hires throughout the year and provide an Employee Enrollment Form and
premium payment to PSPRS within 45 days of hire. We understand that the full premium for that
fiscal year is due regardless of the employee date of hire.
7. We understand that no refunds will be issued for employees that terminate employment.
8. We understand that each following Plan Year after our initial offering for this Plan is July 1st through
June 30th with the payment due prior to August 31st.
9. We understand that retirees from our agency may also be eligible for this plan once we confirm our initial
enrollment into the Plan.
10. We have read and agree to the complete Employer Terms of the Plan.
11. We understand that information regarding this benefit can be located at www.psprs.com.
Our agency does not wish to offer the Cancer Insurance Program to our eligible employees this fiscal year.
1. We understand that if we decline the Plan, it will not be available to our active members or our retirees.
Signature of Agency Representative Date
Printed Name of Agency Representative
Revised Date: 04/27/2016