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June 2010
FSA 200-9
Please return completed form to your employer.
E NROLLMENT F ORM
F LEXIBLE S PENDING A CCOUNTS
(
P LEASE P RINT C LEARLY )
2320 Brighton-Henrietta Townline Rd
Rochester, NY 14623
Website: www.BenefitResource.com
E MPLOYER :
E FFECTIVE D ATE OF E NROLLMENT :
/
/
A. E MPLOYEE I NFORMATION
Member ID:
Employee Name: (Last)
(First)
(
MI)
Home Address: (Street)
(Apt #)
(City) (State) (Zip Code)
Home Phone #:
Birth Date:
/
/
Gender:
Male
Female
Hire Date:
/
/
Employee Status:
Full-Time
Part-Time
E-mail Address: ________________________________________________________________________________________
(Note: Benefit Resource wss
ill
to
only
municate
com use
u
your
regarding
with
eyo-mail
youraddre
Plan.)
The purpose of this agreement is to authorize the election of eligible benefits and the reduction in salary needed to facilitate the employer providing the
employee with selected benefits. This agreement is designed to conform with Section 125 of the Internal Revenue Code.
B. F LEXIBLE S PENDING A CCOUNTS
Please enter your FSA election(s)
.
(Refer to your Plan Highlights for
Per
ele
Pay Ded
ction
uction
maximums)
Plan Year Election
Medical Flexible Spending Account
$ ______________
$ ______________
Dependent Care Flexible Spending Account
$ ______________
$ ______________
C. E MPLOYEE C ERTIFICATION
I have received and read the printed material which explains my Plan and my options under it. I understand that any expenses paid under this Plan
must be eligible expenses as governed by IRS regulations, must be for services provided for me or a qualifying individual and must not be
reimbursed from any other source. I also understand that by signing and submitting this enrollment form, I am making an irrevocable election for
the current Plan Year. Any choices above may be modified only as defined in the Plan. Moreover, I authorize the amount(s) above to be deducted
from payroll as indicated. I also understand that unused amounts in any Flexible Spending Account will be forfeited after the timeframe indicated
in the Plan Highlights.
I understand that Federal law requires financial institutions to obtain, verify and record information that identifies each person with an account. I
also understand that I may be required to provide identifying information (e.g. social security number, address and date of birth) when making
inquiries about my account. I understand that any personal information obtained will not be shared with anyone, including non-affiliated third
parties, except as permitted by law.
If a Beniversal® MasterCard® is associated with my Flexible Spending Account:
I authorize the issuance of a Beniversal MasterCard by a bank chosen by Benefit Resource. I agree to use this card only for eligible medical
expenses under the Plan for me or a qualifying individual and to be bound by all provisions of the Beniversal
Cardholder
and
Agreement
My
Beniversal Use
sent
of
to
Card
me with m
Promises
y card. Furthermore, I understand that if my Beniversal Card is used for expenses other than
eligible medical expenses or if I violate the terms of the
Agreeme
, I may
nt
lose Beniversal Card privileges and will reimburse the Plan for the
expenses. I authorize my employer to deduct any non-approved expense directly from my paycheck on an after-tax basis. I also authorize
expenses for replacement cards and paper follow-up requests to be deducted from my account balance as needed.
Since the IRS requires that certain purchases made with the Beniversal Card be verified for eligibility, I agree to acquire and retain sufficient
documentation for any expense paid with the card and to submit such follow-up documentation to Benefit Resource upon request.
Signature: ________________________________________________________________________________
Date: _____ / _____ / _____
D. P AYROLL D EDUCTION I NFORMATION
Employer must complete this section for employee to be enrolled.
Deduction cycle:
weekly
bi-weekly
monthly
semi-monthly
other _____________________________________
Pay Date of first FSA deduction(s):
_____/_____/_____
Number of pay dates on which FSA deduction(s) will be taken during this Plan Year:
____
Health Insurance Coverage Code: ___ ___ ___ ___ ___ ___
This information is required for Beniversal Cards. The six digit code must
match a code on your Group Insurance Form. Note: If employee is not insured through an employer sponsored health insurance plan, enter
NOMED.
