Fillable FSA FORM INSTRUCTIONS Attached is the 2021 Flexible (Roger Williams University)

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FSA FORM INSTRUCTIONS Attached is the 2021 Flexible (Roger Williams University)

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FSA FORM INSTRUCTIONS
Attached is the 2021 Flexible Spending Health, Dependent Care and
Commuter enrollment form.
The form is set up to be completed electronically. For your convenience,
some of the needed information is already on the form (such as effective
dates).
Please complete the form as follows:
Complete the fillable fields in the first two sections with your personal
information.
In the Deduction/Allocation section,
1. Check the Box(es) of the account(s) you are enrolling in;
2. For the Annual Contribution, simply type in the dollar amount
(digits only) next to the account(s) you checked off and the form
will calculate your Pay Period amount automatically;
3. E-sign and Date the form; and
4. Return to Human Resources no later than November 30
th
:
Email to: human_resources@rwu.edu or
Fax to: Human Resources at (401) 254-3370
Please Send Completed Form To:
Human Resources
One Old Ferry Road, Bristol, RI 02809
Email: human_resources@rwu.edu
Phone: 401-254-3028
Fax: 401-254-3370
Employee Information:
Employer Name: Effective Date:
First Name: Last Name:
Street Address: City: State: Zip:
Email Address: Phone #:
Date of Birth:
Social Security No. (Last 4 Digits):
Dependent/s Information:
Dependent Name: Relation: Date of Birth: Order Debit Card: Yes No
Dependent Name: Relation: Date of Birth: Order Debit Card: Yes No
Dependent Name: Relation: Date of Birth: Order Debit Card: Yes No
Dependent Name: Relation: Date of Birth: Order Debit Card: Yes No
* Please list additional dependents on back side of this enrollment form
Employee's Flexible Benefit Per Pay Deduction / Allocation:
Medical Reimbursement Account:
$$22,750.00
Maximum Annual Contribution*
(set by IRS)
Dependent Care Reimbursement Account:
$5,000.00
Maximum Annual Contribution*
(set by IRS)
$270.00
For Parking
$270.00
For Transit
Maximum Monthly Contribution*
(set by IRS)
Maximum Monthly Contribution*
(set by IRS)
Employee Signature
:
Date:
Plan Administrator:
London Health Administrators
(1) My employer will be deducting the allocations stated above from pay check for the purposes of funding my Flexible Spending Account plan(s).
(2) My accounts will not automatically renew. During each annual open enrollment period, I understand that I must complete a new enrollment form
indicating my account contributions for each new plan year.
(3) I cannot change or revoke this agreement at any time during the plan year unless I have a change in family status, marriage, divorce, death of spouse or
child, birth or adoption of child, termination or commencement of employment of a spouse, or such other qualifying events allowed by the Internal Revenue
Code that will permit a change or revocation of an election.
(4) London Health Administrators may reduce, cancel, or otherwise modify this agreement in the event they believe it is advisable in order to satisfy certain
provisions of the Internal Revenue Code.
(5)This agreement is subject to the terms of the Company's Flexible Spending Benefits Plan, as amended from time to time, which shall be governed under
applicable laws, and revokes any prior agreement relating to such plan(s).
(6) By signing this form, I agree to the terms and procedures listed herein.
Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield AssociationBlue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association
Commuter Reimbursement Account:
I Understand That:
Flexible Spending
Dependent Care and Commuter Account
Enrollment Form
Annual Contribution:
Per Pay Period:
Annual Contribution:
Per Pay Period:
Annual Contribution:
Per Pay Period:
Annual Contribution:
Per Pay Period:
# of Pay Periods _______
Date of First Payroll ________
# of Pay Periods _______
Date of First Payroll ________
# of Pay Periods _______
Date of First Payroll ________
# of Pay Periods _______
Date of First Payroll ________
Roger Williams University and School of Law
01/01/2021
$ 0.00
26
1/15/21
26
1/15/21
$ 0.00
26
1/15/21
$ 0.00
26
1/15/21
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FSA FORM INSTRUCTIONS Attached is the 2021 Flexible (Roger Williams University)

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Completed 1 February 2021

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