Flexible Spending Account Enrollment Form
Allied Benet Systems, Inc.
200 W. Adams St. Suite 500
Chicago, IL 60606
alliedbenet.com
P 312.906.8080
F 312.906.8879
eligibilitydept@alliedbenet.com
Secon I. Employer/Employee Informaon PLEASE PRINT
Employer Name: Group Number: Employer Locaon (if applicable):
Employee Name: Sex: Employee SSN: Date of Birth: Flex Plan Year:
Address: City: State: Zip:
Employee E-mail Address: Dayme Phone:
Secon II. Elecon(s)
Use the table below to select your Flex benets.
Annual / Mid-Year elecon pledge Divided by
# of pay periods of the: annually
(Plan Year) / Mid-Year
Equals Deducon from each pay period
I elect to parcipate in the
Health Flexible Spending Account
$ / = $
I elect to parcipate in the
Dependent Care Assistance
$ / = $
(Plan Year Example)
$ 2,550.00 / 24 = Example $106.25
Secon III. Allied Flex Debit Card SSN and DOB are required. Dependent must be over 17.
Please complete the informaon below for all dependents who should have an Allied Flex Debit Card
Spouse Name: Date of Birth: SSN:
Keep current dependent card acve.
Request new dependent debit card.
Dependent Name: Date of Birth: SSN:
Keep current dependent card acve.
Request new dependent debit card.
Dependent Name: Date of Birth: SSN:
Keep current dependent card acve.
Request new dependent debit card.
Secon IV. Direct Deposit
I would like to parcipate in Direct Deposit Yes No
If yes, please complete the aached “Flex Direct Deposit Enrollment Form”
and include a voided check.
I am currently parcipang in direct deposit. Please keep current banking informaon on le.
Secon V. Parcipant Cercaon
I cerfy the above informaon is true and correct and I authorize any premiums and HSA contribuons, if applicable, to be paid on a pre-tax basis pursuant to Internal Revenue Code
Secon 125. I understand that any amounts which are not used for eligible expenses incurred during the Plan Year or Grace Period, will be forfeited in accordance with current Plan pro-
visions and tax laws. I further understand that the salary reducon(s) will be in eect for the Plan Year and cannot be revoked except as authorized by current Plan provisions and laws.
Employee Signature: Date:
IF YOU DECLINE PARTICIPATION: The benets of the Plan have been thoroughly explained to me and I decline parcipaon.
Employee Signature: Date:
Employer Use Only (Required for processing)
Employee’s Flex Plan Eecve Date First Payroll Date Payroll Cycle
I agree this form is correctly lled out by the Employee.
HR Signature:
