This signed document will acknowledge the receipt and ...
NICHOLLS STATE UNIVERSITY
SUPPLEMENTAL BENEFITS SOLICITATION POLICY
ACKNOWLEDGEMENT RECEIPT
This signed document will acknowledge the receipt and understanding of the Nicholls State University Supplemental Benefits Solicitation Policy and other information as set forth in this acknowledgement receipt.
Vendors are required to return all payroll deduction authorization forms to the University Benefits Coordinator in the Office of Human Resources. Payroll deductions will be processed during the pay period in which they are received or the first pay period of the new plan year, as designated by the employee. Any changes and/or corrections made due to the payroll deduction authorization form being completed inaccurately are the responsibility of the vendor. The vendor representative must correct the payroll deduction authorization form, with the employee, and resubmit the corrected payroll deduction authorization form to the University Benefits Coordinator. Nicholls State University will not be responsible for any errors or omissions on the behalf of the vendor or the vendor representative. Assistance shall only be provided once the vendor has shown that all other means of obtaining a signed corrected payroll deduction authorization form have been exhausted.
No payroll deductions will be entered into the payroll system unless a signed payroll deduction authorization form has been submitted to the University Benefits Coordinator, including enrollments, terminations, and/or changes to premium amounts.
I, _____________________________________, (print name) certify that I have received, read, and acknowledge the University Supplemental Benefits Solicitation Policy, as well as the acknowledgement receipt and will abide by and follow all of the procedures and requirements as set forth by Nicholls State University through this University Supplemental Benefits Solicitation Policy. I further understand that any violation by any vendor or vendor representative shall result in all solicitation privileges for that vendor being revoked.
______________________________________ ________________________
Vendor/Vendor Representative Signature Date
Rev. 09/04
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