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401 K Form

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401(k) Plan Enrollment Form

401(k) PLAN ENROLLMENT FORM

SAMPLE FORM

INSTRUCTIONS:

  1. Please complete all sections of this form to enroll in the company’s 401(k) plan.
  2. Required fields are marked with an asterisk (*).
  3. Submit the completed form to Human Resources.

SECTION 1: PERSONAL INFORMATION

SECTION 2: CONTRIBUTION ELECTIONS

I authorize my employer to withhold the following amount from my eligible compensation and deposit it into my 401(k) account:

%
%
$
$

Note: Your employer matches 100% of your contributions up to 5% of your eligible compensation.

SECTION 3: INVESTMENT ELECTIONS

Please indicate how you would like your contributions invested:

Select ONE ‘PRO Account’ from the three options below and then proceed to Step 3.

Enter a percentage next to each desired fund; contributions will be invested accordingly. Selection must equal 100%.

SECTION 4: BENEFICIARY DESIGNATION

Please designate the beneficiary(ies) who will receive your 401(k) plan benefits in the event of your death:

Primary Beneficiary

%

SECTION 5: AUTHORIZATION

By signing below, I acknowledge the following:

  • I authorize my employer to deduct the specified contribution amount from my compensation.
  • I have received and read the Summary Plan Description.
  • I understand that my election will remain in effect until I submit a new form to change or terminate it.
  • I understand the investment options available to me and have made my selections accordingly.
* Required fields

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