Blyco Electric Enrollment - Web Book - 2025 - Flipbook - Page 22
Blyco Electric, LLC 401(k) Plan
Enrollment / Information Change Form
Blyco Electric, LLC
Attn: Stephnie Hall
4111 Brandy Blvd.
Ft. Pierce, Florida 34981
Certified Benefits Corp
1111 Douglas Avenue
Altamonte Springs, FL 32714
Please complete the following accurately. Print clearly using Black Ink.
SECTION 1: General Information
□
NEW ENROLLMENT
□
INFORMATION 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
❑
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 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.
Note: Contribution limits for 2025 not to exceed a total of $23,500 if under the age of 50, or $31,000 if age
50 or over. Also available to individuals aged 60, 61, 62, or 63 is The Super Catch-Up. This is NOT in
addition to the regular catch-up contribution. You can use either the regular catch-up limit ($7,500 in 2025)
OR the super catch-up limit ($11,250 in 2025), but not both.
❑
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: ___________________________
