THE EVERETT CLINIC 401(k) RETIREMENT PLAN
NEW ENROLLEE FORM
1. PERSONAL INFORMATION (Please print clearly)
Name:______________________________________________ Employee Number:
__ Date of Hire
2. 401(k) CONTRIBUTION ELECTION
401(k) Pre-Tax Contribution

A. Please deduct
% per pay period of my gross salary on a pre-tax basis and contribute my salary deferral
contributions to the Plan. (The percentage selected may be from 1% to 85% of your paycheck)
401(k) Roth After-Tax Contribution

B. Please deduct
% per pay period of my gross salary on an after-tax basis and contribute my salary deferral
contributions to the Plan. (The percentage selected may be from 1% to 65% of your paycheck)
Please Note: For 2015, the maximum is $18,000. If you are 50 years old or will attain age 50 by 12/31/2015, the maximum is
$24,000. Your deferrals will be stopped when they reach this cap. Please contact your Retirement team to set a limit if you have
contributed to a 401(k) at another employer during the year. 401(k) deductions are not taken from certain bonus and incentive award payments
(examples: wellness bonuses, long-term recognition awards, hiring bonus, retirement bonus, outstanding contribution awards, car pool reimbursements,
mileage stipend, cell phone stipend, etc.) All required payroll deductions are subtracted first. Your deduction will be limited to your net paycheck.

C. I DO NOT wish to contribute to the 401(k) Plan at this time. I understand that I may reconsider my decision at any
future enrollment date described in Section 5.
3. INVESTMENT ELECTIONS FOR CONTRIBUTIONS
Asset Allocation Models
_______%
_______%
_______%
Conservative Pre-Mixed Portfolio ←
Moderate Pre-Mixed Portfolio ←
Aggressive Pre-Mixed Portfolio ←
Core Investment Options
These three Pre-Mixed
Portfolios are designed to
be a single investment
option. Refer to the
Investment Options for
more information.
%
Stable Value Fund
%
Bond Index Fund
_______%
Bond Portfolio
%
Large Company Index Stock Fund
%
Large Company Stock Portfolio
%
Mid Company Index Stock Fund
%
Mid Company Stock Portfolio
_______%
Small Company Index Stock Fund
_______%
Small Company Stock Portfolio
_______%
International Company Index Stock Fund
_______%
International Company Stock Portfolio
= 100 % TOTAL (Percentages must be in multiples of 1% and must total 100%)
4.
TELEPHONE/INTERNET
AUTHORIZATION
INSTRUCTION
I hereby authorize Trautmann, Maher & Associates
(TM&A) to act on telephone/Internet instructions
with respect to the investment of assets held in my
account, from any person representing himself or
herself to be me furnishing proper identifying
information. I acknowledge that neither TM&A nor
The Everett Clinic will be liable for any loss, legal
obligation, cost or expense for acting upon such
telephone/Internet
instructions
when
such
telephone/Internet instructions are believed by
TM&A to be genuine, even if such instructions are in
fact not given by me. I understand that my
telephone/Internet instructions to TM&A are subject
to the terms and conditions of The Everett Clinic
Profit Sharing and 401(k) Employee Savings Plan &
Trust and any other such conditions and limitations
as may be communicated to me from time to time. I
further understand that my right to give
telephone/Internet instructions to TM&A is subject to
termination at any time by The Everett Clinic or by
TM&A.
5. AUTHORIZATION AND EFFECTIVE DATE
I understand that (1) the effective date of these elections is the next possible payroll processing period after the form is received in
Accounting, (2) this payroll election may be suspended/revoked at any time, (3) my contribution election in Section 2 may be reduced by the
Plan Administrator if necessary to meet Internal Revenue Service qualification rules (4) my salary reduction agreement remains in effect until
I revoke the agreement (5) it is my responsibility to review my TEC pay stub information on Lawson for accuracy regarding this salary
reduction agreement.
EMPLOYEE SIGNATURE
DATE
Please return the completed form to: The Everett Clinic, Attn: Accounting Department – Retirement Plan, 3901 Hoyt Avenue, Everett, WA 98201
For Accounting Department Use Only:
Authorization
Date Received
REV 12.19.014