Please type or print all information.
ParticiPant information
Company name:
Employee/participant name
Last 4 digits of Social Security #:
Employee Address:
City: State: Zip:
Phone: Email:
request additional debit card(s)
Up to 4 additional cards can be issued to individual family members 18 years and older
1) Name: Social Security #:
Date of Birth:
2) Name: Social Security #:
Date of Birth:
3) Name: Social Security #:
Date of Birth:
4) Name: Social Security #:
Date of Birth:
certification
I certify the information on this form is accurate, complete, and true. I also certify that I will claim re-
imbursement/ use debit card for only eligible expenses incurred during the plan year and only for the
eligible plan participants. I certify that these expenses have not been or will not be reimbursed under
this or any other benet plan. I further certify I will not claim these or any other expenses reimbursed
through this plan, as an income tax deduction. I assume all liability for taxes and penalties out of
any disallowed deduction/credit. I understand I can be reimbursed/use debit card only for qualied
expenses incurred during the plan year.
signature
Employee Signature:
Date:
BASIC FLEX
Additional Debit Card
Request Form
COMPLETE THIS FORM AND
MAIL OR FAX TO:
9246 PORTAGE INDUSTRIAL DR.
PORTAGE, MI 49024
P 800-444-1922 ext 3
F 800-658-7248
sales@basiconline.com
