RLF Enrollment - Web Book - Ready - Flipbook - Page 21
PROFIT SHARING PLAN FOR THE EMPLOYEES OF
ROGERS, LOVELOCK & FRITZ, INC.
Mr. Scott Fote
Rogers, Lovelock & Fritz, Inc.
4750 New Broad Street
Orlando, FL 32814
Enrollment / Information Change Form
Certified Benefits Corp
1111 Douglas Avenue
Altamonte Springs, FL 32714
Please complete the following accurately. Print clearly.
SECTION 1: General Information
□
NEW ENROLLMENT
□
INFORMATION UPDATE/CHANGE
_______________________________________________________________________
Last Name
First Name
M.I.
_________-_________-_________
Social Security Number
_______________________________________________________________________
Mailing Address
_____________________
Date of Birth (mm/dd/yy)
_______________________________________________________________________
City
State
Zip Code
____________________
Date of Hire (mm/dd/yy)
(__________)__________-__________
Home Telephone
(__________)_________-__________
Mobile Phone [REQUIRED FOR SECURITY & ONLINE ACCESS]
_______________________________________________________________________
Email Address [REQUIRED FOR SECURITY & ONLINE ACCESS]
□
YES, send my statement electronically
(please include email address for notification)
SECTION 2: Contribution Election (please select one of the two options below)
❑
I want to make pre-tax salary deferral contributions to the Plan. I authorize my employer to deduct
$__________ or __________.0% of my gross salary from each paycheck (not to exceed a total of $22,500
in 2023 if under the age of 50, or $30,000 in 2023 if age 50 or over) and to credit that amount to my pre-tax
salary deferral portion of my account.
❑
I want to make post-tax (Roth 401(k)) salary deferral contributions to the Plan. I authorize my employer to
deduct $__________ or __________.0% of my salary from each paycheck and to credit that amount to my
post-tax salary deferral portion of my account.
❑
I do not wish to contribute to the Plan at this time.
Signature – Please review to make sure that you have completed each accurately, fully, and legibly. Please return
this form to your employer for acceptance.
Employee Signature: __________________________________________Date: ___________________________
Employer Signature: __________________________________________Date: ___________________________
