Flexible Spending Account Enrollment Form

Flexible Spending Account
Enrollment Form
Employer Name: ____________________________________________________________________________
Participant Name (First, MI, Last): ______________________________________________________________
Social Security Number: ______ - ______ - ____________ Phone Number (________) _________________
Address: ___________________________________________________________________________________
City, ST, ZIP: ________________________________________________________________________________
Date of Birth: _______/________/___________
Date of Hire: _______/________/___________
Email Address: ___________________________________________________
FSA Benefit Election
Per Pay Period Amount
Total Annual Amount
 Health Care Election—Standard
 Health Care Election—Limited
 Dependent Care Election
# Pays Per Year
Carrier Information.
Check the boxes if you are enrolled in any of these benefits through your employer. Medical;  Dental;  Vision;  Rx
Automated Claims Transfer: If you are eligible for ACT (check with your Employer), certain expenses submitted through your
insurance provider may automatically be reimbursed to you, unless you or any of your dependents have Coordination of Benefits (COB) with other Plans. This feature is not applicable to Health Spending Card holders.
I do not want ACT or I have COB and am not eligible for ACT.
Spouse/Dependent Information (Attach additional pages if necessary)
Social Security Number
 I do not have a spouse or dependents
Date of Birth
Direct Deposit Election (Complete this section if you want Direct Deposit of your reimbursements)
Type of Account (Check one):
 Checking
 Savings
Name of Bank: _____________________________________________________________________________
Transit ABA Routing #: ___________________________ Account #: ________________________________
Participant Authorization—Return signed form to your Employer.
By signing below I agree to participate in my employer’s pre-tax program and certify that I understand and will comply
with the regulations governing such Plan. I understand the basic provisions provided on page 2 of this form are guidelines only and that my Plan’s Summary Plan Descriptions prevails.
Participant Signature: ______________________________________________________ Date: _________________
To Be Completed by the Employer
 New Hire  Open Enrollment
Effective Date: _____________
First Payroll Deduction Date: __________________
Notify Payroll of deduction amount and date
Keep copy of Enrollment Form for your records
Forward copy of Enrollment Form or provide data on a file to
Lifetime Benefit Solutions
This Plan has employer funded money:  Yes  No. If Yes,
ER Money:
Payroll Based?
Annual Amount
 Health Care
 Yes  No
 Dependent Care
 Yes  No
Page 1 of 2
Flexible Spending Account
Enrollment Form
Direct Deposit:
Direct Deposit sends claim reimbursement payments directly to your personal bank account. Direct deposit
notification statements will be emailed to you with the details of the reimbursement. If you provide incorrect
information and corrective transactions are required, your account may be charged a $25 processing fee. Direct deposit transactions are not subject to the typically imposed $30 check minimum.
Things to Consider Upon Enrollment:
Your FSA account refers to the combined health care and dependent care components.
By enrolling in the FSA program, you agree to have your compensation reduced by the amount elected.
Your election applies to this Plan year only. To continue in the Plan, you must re-enroll each year.
Annual health care elections are available for reimbursement in full on the first day of the Plan year.
Dependent care elections are available for reimbursement based on current balance.
FSA accounts are tracked separately and cannot be combined. These elections are in addition to any premiums you pay on a pre-tax basis for employer sponsored health insurance.
The dependent care account pays for daycare services needed for a qualifying dependent while you work.
A qualifying dependent is a child under age 13 who is claimed as a dependent on your federal income tax
return (special rules apply for divorced parents), a disabled spouse, and any other dependent on your tax
return who resides in your home and is physically or mentally disabled.
You may file claims for reimbursement from your FSA accounts for qualified expenses incurred during the
Plan year and after becoming a participant. Depending on the provisions in your Plan, some or all of the
funds remaining in your FSA account after the end of the Plan’s run-out period may be forfeited.
You will pay the Employer for any tax liability or penalties it incurs if you are reimbursed for an expense
that is not a qualified expense, unless you repay the amount or off-set that amount with additional eligible
claims within the same Plan year.
You cannot change the amount of your FSA contributions or pre-tax health insurance premiums, unless
you have a qualifying “life change” event as defined in the Plan and satisfy any other conditions for changes contained in the Plan and tax law.
Your FSA contributions will terminate when your employment terminates. You must check with your Employer to determine if you can elect to continue your health care contributions on an after-tax basis, as
allowed under COBRA.
Your employer may change the amount of your FSA elections if necessary to satisfy tax law requirements.
You understand that you must provide acceptable documentation for every claim you submit, including
Health Spending Card purchases upon request.
You will keep copies of all documents submitted to Lifetime Benefit Solutions for your own personal records; Lifetime Benefit Solutions is not responsible for retaining copies of your receipts beyond the current
Plan year.
Flexible Spending Accounts and Health Reimbursement Accounts are subject to Federal Law which generally supersedes state law.
Any person who qualifies as your dependent for federal income tax purposes, or your child even if he or
she does not qualify as your dependent for federal income tax purposes but only through the end of the
calendar year in which the child reaches age 26.