Jazz Benefits Pad

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Employee Name:

David Todica

Employee#:

807213

EMPLOYEE ELECTION FormI wish to continue with my:Check one:

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Basic benefit coverage and pension ($484.01) or;

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Basic benefit ($239.95) or;

Pension coverage ($244.06) or;

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I decline to continue both my benefit and pension coverage

I, Pt'l\j) 10D\ CA , # ~D1d\3 acknowledge I am responsible , for payment of any benefit or pension coverage I have elected to continue during my absence. I understand I will be not be covered for any optional benefit I declined (including MSP or AHC, if applicable) and must re-apply for coverage upon my return to active employment. I also understand Jazz will not match my contributions towards the pension plan. if I decline to contribute

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Signed:_~-=====~,~A=::::.