Your Prepaid Mastercard is issued by The Bancorp Bank pursuant to license by Mastercard International Incorporated. Mastercard is a registered trademark of
Mastercard International Incorporated. The Bancorp Bank; Member FDIC.
09/2017 CBP 300-1
ENROLLMENT FORM
COMMUTER BENEFIT PLAN
(PLEASE PRINT CLEARLY)
EMPLOYER:
EFFECTIVE DATE OF ENROLLMENT: / /
A. EMPLOYEE INFORMATION
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 (please check one): Full-Time Part-Time
Email Address: ______________________________________________________________________________________
(Note: Benefit Resource, Inc. will only use your email address to communicate with you regarding your plan.)
B. COMMUTER BENEFIT PLAN (CBP) ACCOUNTS
Please enter your CBP election(s):
Type of Account Monthly Election
Parking $ ______________
Mass Transit $ ______________
C. EMPLOYEE CERTIFICATION Return signed form to your employer.
I have received and read the printed material which explains my Commuter Benefit Plan and my options under it. I understand that
any expenses paid under this plan must be eligible workplace commuting expenses as governed by Internal Revenue Service
regulations and must not be reimbursed from any other source. I also understand that by signing and submitting this enrollment
form, I am making an election that will remain effective until a change form is submitted during open enrollment or when a
permissible change has occurred. Any choices above may be modified only as defined in the plan.
I authorize the amount(s) above to be deducted from payroll as indicated and also authorize any necessary advance on salary
deduction (as described herein).
I authorize the issuance of a Prepaid Mastercard
®
(“Card”). I agree to use the Card only for eligible plan expenses and to be bound
by all provisions of the Cardholder Agreement sent to me with my Card. Furthermore, I understand that if my Card is used for
expenses other than those defined in the plan or if I violate the terms of the Cardholder Agreement, my account may be suspended
and I will reimburse the plan for the expenses. I also agree to have any non-approved expense and/or applicable replacement card
expense deducted from my paycheck on an after-tax basis as an advance on salary.
I understand that Federal law requires all financial institutions to obtain, verify and record information that identifies each person
who opens an account. I also understand that I may be required to provide identifying information (e.g. Member ID, address and
date of birth) when making inquiries about my Card. I understand that any personal information obtained will not be shared with
anyone, including non-affiliated third parties, except as permitted by law.
Signature: ______________________________________________________________________ Date: _____ / _____ / ______
D. PAYROLL DEDUCTION INFORMATION Employer must complete this section for employee to be enrolled.
Deduction cycle: monthly semi-monthly bi-weekly (2 per month) weekly (4 per month)
Pay Date of first CBP deduction(s): _____/_____/_____ Card Issue Month: __________________
245 Kenneth Drive
Rochester NY 14623-4277
Phone: (800) 473-9595
www.BenefitResource.com
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