UNDERSTANDING OF AGREEMENTS
I have received the printed material explaining the Plan and my options under the Plan, and I
understand that by signing this form, I am making an election which may not be changed for this Plan
year other than as permitted by law and the Plan.
I understand that by electing to be covered under the applicable Employer’s insurance plan(s), my
portion of the premium is automatically reduced from pre-tax wages under the Flexible Compensation
Plan, if applicable. Further, I understand that if I do not incur expenses this Plan Year in the amount
which I have elected for each benefit, the law requires that I forfeit any unused amounts.
I authorize the reduction of these amounts from my paychecks and acknowledge that these amounts
are to be credited to my Flexible Compensation accounts. I authorize the Administrator to draw upon
my account to reimburse me for eligible expenses incurred by me during the Plan Year. I understand
that request for reimbursement from the reimbursement plan(s) will only be processed if I comply
with the terms and conditions of the applicable plan. I also understand that the Plan Administrator
and Third Party Claims Administrator may establish rules and procedures from time to time, which
also govern processing reimbursement requests. In addition, the Plan Administrator may establish
rules and procedures regarding payment of remaining reimbursement contributions upon
termination of employment in accordance with the applicable Flexible Benefit Plan Document(s). The
Employer and Plan Administrator may take appropriate legal action to assure that reimbursements
are made in accordance with the terms and conditions of the reimbursement plan(s).
DEPENDENT CARE
I understand that for this Plan Year, I may be reimbursed for dependent care expenses up to the
maximum of (1) Five Thousand Dollars ($5000), or Two Thousand Five Hundred Dollars ($2500) if
married filing separate, (2) my spouse’s earnings, if applicable, or (3) 50% of my earnings, whichever
is least. I also understand that in order to receive reimbursement, I must submit receipts or other
evidence that indicate who was cared for, dates of service, the actual amount paid along with the
name, address and social security/tax identification number or the provider of these services. I
understand that I or my spouse, if applicable, may not elect to receive the tax credit for the
dependent care expenses that I have been reimbursed for under the Plan.
HEALTH CARE/FSA MEDICAL EXPENSES
I understand that for this Plan Year, I may be reimbursed for expenses incurred for my medical care
and the medical care of my spouse and dependents which are not covered by medical insurance or
other plans up to the maximum amount deemed by the Plan. The “dependent” relationship must exist
when the charges were incurred. If I claim reimbursement for these expenses under the Plan, the
amount of the reimbursement will be tax free.
Eligible medical expenses include any expenses incurred for diagnosis, cure, treatment, mitigation,
prevention of disease, purpose of affecting any bodily function or structure, prescription drugs, or
insulin per IRS guidelines from the “Patient Protection and Affordable Care Act”.
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