HTML Preview Assistant Payroll Deduction Form page number 1.
RETURN TO:
College of Graduate Studies
Main Campus
University Hall 3240
Mail Stop 933
Graduate Assistant Payroll Deduction Authorization Form
Please read terms of enrollment before completing this form.
As a University of Toledo Graduate Assistant, you are eligible to payroll deduct University Health Insurance.
This process does not apply to items that are not billed through your University of Toledo account or other
charges (i.e. cell phone) not specified here. Before opting to payroll deduct the University Health Insurance,
please read carefully the terms of enrollment. Verification of enrollment will be sent to your email address in
3-5 business days.
Last Name:
First Name:
Rocket ID:
Ex: R0000xxxx
Date of Birth:
Ex: mm/dd/yyyy
E-mail:
Health Insurance Payroll Deduction Option: Fall or Spring (check only one)
Enroll me in one of the following payroll deduction's for my University of Toledo Health Insurance:
By submitting this form, I acknowledge that I have read the terms of enrollment and viewed the rates of
deduction and authorize the deduction of those amounts from my bi-weekly UT payroll check.
(
alternative to e-submit, please sign and return to College of Graduate Studies)
For information or questions regarding this form, email Mary Main, [email protected] or call (419) 530-2283
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