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FLEX SPENDING ACCOUNT PLAN
2020 BENEFIT ELECTION FORM
PLEASE PRINT THE FOLLOWING INFORMATION
EMPLOYEE INFORMATION
Company Name:
Employee Name (Last, First): Social Security
Number:
Address:
City:
State: Zip:
E-Mail:
Daytime Phone:
Date of Birth:
Eective Date: Pay Cycle:
Weekly
Other: _____________
Bi-Weekly
Semi-Monthly
MEDICAL CARE REIMBURSEMENT / WELLNESS PLAN
This plan is a fund that will help you to save money on expenses that normally would not be paid by your traditional Health Insurance Plans and can be
utilized to help oset your out of pocket Medical, Dental, Vision, and Rx expenses. Expenses are paid with Pre-Tax dollars. You may elect to Pre-Tax up to
$2,750.00 for the plan year. You will be issued a Take Care Visa Flex Card to pay for these expenses at the time of purchase. Remember that if you are a
current participant in the Medical Care Reimbursement Plan, and have a remaining balance, your company might oer a grace period to use your
balance, or oer to roll any unused funds (up to $500) to the next plan year. This money is in addition to any benet election that you make at this time.
Enter dollar amount to deposit per pay: $ _____________ , or $ _____________ annually.
DEPENDENT CARE REIMBURSEMENT ACCOUNT
You may elect to pay for your Dependent Care expenses or eligible babysitting with Pre-Tax dollars. You may elect to deposit up to $5,000.00 annually
in your Dependent Care Reimbursement Account. Once these expense items are claimed, payment of these expenses will be issued on a Pre-Tax basis,
saving you Federal, State and FICA taxes. You will be issued a Take Care Visa Flex Card to pay for these expenses. You may arrange to have your Day Care
claims issued automatically to you with only one annual claim ling.
Enter dollar amount to deposit per pay: $ _____________ , or $ _____________ annually.
AUTHORIZATION
I have read all of the enrollment material explaining this benet plan. My Company and I agree that my cash compensation will be redirected according
to my elections. These elections shall be in addition to other agreements or benet programs maintained by my employer. I cannot change or revoke
my elections on this plan unless I have a qualied status change during the plan year. Prior to the rst day of each plan year I will be oered the
opportunity to change my elections for the following plan year.
I understand that I must be able to provide receipt documentation upon request for any and all out-of-pocket expense costs as accessed through this
plan.
________________________________________
Employee Signature
________________________________________
Date
click to sign
signature
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