Long Term Disability Plan Updated on: November 1, 2016 Election Form If you do not return this form, your Long Term Disability benefit will remain taxable. You now have the ability to designate a TAX FREE long-term disability benefit. You may elect for your benefit to remain TAXABLE or change to a TAX FREE benefit option during the annual open enrollment period. Changes will be effective upon receipt. If you want a tax free benefit, please check below:Change from a TAXABLE benefit to a TAX FREE benefit. I understand that: I would receive 60% of my basic monthly earnings less other income benefits up to a maximum benefit of $8,000 per month or $96,000 per year, if I were to become disabled and could no longer work, the Long Term Disability premium paid by Austin College will be charged to me as imputed income and I will pay the income taxes on the premium, and therefore any disability benefit I receive will be tax free to me. Yes Signature:I hereby certify that this is my request and will be in place until revoked in writing to the Human Resources Department. As certification for the information listed above, my Austin College email address will act as my signature.Full Name:* Austin College Email Address*