The employer maintains a Plan Document; if anything in this document conflicts with the Plan Document, then the Plan Document controls.
The Beniversal Prepaid MasterCard is issued by The Bancorp Bank pursuant to license by MasterCard International Incorporated.
The Bancorp Bank; Member FDIC. MasterCard is a registered trademark of MasterCard International Incorporated.
Rev. June 2014 FSA 200-9
ENROLLMENT FORM
FLEXIBLE SPENDING ACCOUNTS
(PLEASE PRINT CLEARLY)
EFFECTIVE DATE OF ENROLLMENT: / /
Employee Name: (Last) (First) (MI)
Home Address: (Street) (Apt #)
(City) (State) (Zip Code)
Home Phone #: Birth Date: / / Gender: Male Female
Hire Date: / / Employee Status: Full-Time Part-Time
Email Address: ________________________________________________________________________________________
(Note: Benefit Resource, Inc. will only use your email address to communicate with you regarding your plan.)
The purpose of this agreement is to authorize the election of eligible benefits and the reduction in salary needed to facilitate the employer provi ding the
employee with selected benefits. This agreement is designed to conform with Section 125 of the Internal Revenue Code.
B. FLEXIBLE SPENDING ACCOUNTS (FSAs) Please enter your FSA election(s) below.
(Refer to your Plan Highlights for election maximums) Per Pay Deduction Plan Year Election
Medical FSA $ ______________ $ ______________
Note: If you or your spouse has a Health Savings Account (HSA), contributions cannot
be made to the HSA while there is coverage under a Medical FSA.
Dependent Care FSA $ ______________ $ ______________
C. EMPLOYEE CERTIFICATION Return signed form to your employer.
I have received and read the printed material which explains my plan and my options under it. I understand that any expenses paid under this plan
must be eligible expenses as governed by Internal Revenue Service (IRS) regulations, must be for services provided for me or a qualifying individual
and must not be reimbursed from any other source. I also understand that by signing and submitting this enrollment form, I am making an irrevocable
election for the current plan year. Any choices above may be modified only as defined in the plan. Moreover, I authorize the amount(s) above to be
deducted from payroll as indicated. I also understand that unused amounts in any Flexible Spending Account may be forfeited a fter the time frame
indicated in the Plan Highlights.
I understand that Federal law requires financial institutions to obtain, verify and record information that identifies each p erson with an account. I also
understand that I may be required to provide identifying information (e.g. social security number, address and date of birth) when making inquiries
about my account. I understand that any personal information obtained will not be shared with anyone, including non-affiliated third parties, except as
permitted by law.
If a Beniversal
®
Prepaid MasterCard
®
is associated with my Flexible Spending Account:
I authorize the issuance of a Beniversal Card. I agree to use this card only for eligible medical expenses under the plan for me or a qualifying
individual and to be bound by all provisions of the Cardholder Agreement and card promises sent to me with my card. Furthermore, I understand
that if my Beniversal Card is used for expenses other than eligible medical expenses 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 authorize my employer to deduct any non-approved expense directly
from my paycheck on an after-tax basis. I also authorize expenses for replacement cards and paper followup requests to be deducted from my
account balance as needed.
Since the IRS requires that certain purchases made with the Beniversal Card be verified for eligibility, I agree to acquire a nd retain sufficient
documentation for any expense paid with the card and to submit such followup documentation to Benefit Resource upon request.
Signature: ________________________________________________________________________________ Date: _____ / _____ / _____
D. PAYROLL DEDUCTION INFORMATION Employer must complete this section for employee to be enrolled.
Deduction cycle: weekly bi-weekly monthly semi-monthly other _____________________________________
Pay Date of first FSA deduction(s): _____/_____/_____
Number of pay dates on which FSA deduction(s) will be taken during this plan year: ____
Health Insurance Coverage Code: ___ ___ ___ ___ ___ ___ This information is required for Beniversal Cards. The six digit code must
match a code on your Group Insurance Form. Note: If employee is not insured through an employer sponsored health insurance plan, enter
NOMED.
245 Kenneth Drive
Rochester NY 14623-4277
Phone: (800) 473-9595
www.BenefitResource.com
