* = required field
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Employee Flexible Spending Account (FSA) Enrollment Form
P.O. Box 70168, Springfield, OR 97475-0110
Phone (541) 485-7488 (800) 422-7038
FAX (541) 485-8759 (800) 575-1109
Section 1 - Employment Information please print
Employer Name*
Division or
Date of Hire
(Required for mid-year
FSA Effective
PSA Member ID
ployer’s ID (
assigned by the employer
to each specific employee)
Number of hours
worked per week
Section 2 - Employee Information please print
Last Name*
First Name*,
Date of Birth*
Mailing Address*
Primary phone
Email address (If provided,
notifications may be sent via email.)
Beneficiary Name and Relationship
Section 3 -
Premium Payment Component
I agree to have my salary reduced on a pre-tax basis to pay the premiums offered by my employer for medical and
hospitalization insurance, major medical insurance, dental insurance, vision insurance and/or other qualified benefits under
Section 125 for myself and my eligible family members. If my employer uses the evergreen method of enrollment; I will remain
enrolled in the Premium Payment Component until I notify my employer in writing that I do not wish to have my share of the
premium(s) deducted on a pre-tax basis.
Section 4 - Flexible Spending Account Election Information
(as offered)
Employee Pay
# of
Account Information
Dependent Care
$ x
= $
Child care expenses (for dependents
younger than13) and elder care expenses
you incur while at work or school.
Health FSA
General Purpose
Health FSA
= $
igible medical, dental, vision, and
preventive care expenses for yourself and
your dependents.
Limited Purpose
Health FSA
= $
Eligible dental, vision, and preventive care
expenses for yourself and your dependents.
Employees contributing to a health savings
account may elect this plan.
Limited Scope
Health FSA
= $
Eligible dental and vision for yourself and
your dependents. Employees ineligible for
the group-sponsored medical plan may
elect this plan.
Check here if you or your dependents are enrolled (or plan to enroll) in a health savings account.
Check here if you are not eligible (or won’t be eligible) in your employer’s group sponsored medical plan.
122CLB 042017
Section 7 - Participant Authorization or Waiver signature required
Participant Authorization
I hereby certify the information provided on this form is correct and true to the best of my knowledge, and that the children
for whom I will be claiming dependent or childcare expenses either reside with me in a parent-child relationship or are
legally dependent on me for their support. I understand that any amount remaining in my account(s) not used for eligible
expenses incurred during the plan year may be forfeited in accordance with current Plan provisions and tax laws. I further
understand that the flexible compensation reductions will be in effect for the plan year and cannot be revoked unless I
experience a qualified change in status. I also understand that the reductions may correspondingly reduce my future Social
Security benefits.
If I lose coverage under the Health FSA component as a result of a qualifying event (for example, termination of
employment or cessation of eligibility because of a reduction in hours of employment), I may be entitled to elect coverage
continuation under the Health FSA allowed by my employer’s Plan. I understand that I cannot be forced to repay or
voluntarily repay the employer for any amounts exceeding my Health FSA account balance.
Participant Waiver
I do not wish to participate in the Plan, and waive enrollment for the Health FSA Component, DCAP Component, and
Premium Payment Component. I understand that by refusing to participate, I will be unable to enroll this plan year unless
my employer allows mid-year changes and I experience a qualifying event, in accordance to the IRS Code section 125, and
submit the change within 30 days of the qualifying event.
Any person who, with an intent to knowingly defraud, files this application with materially falsified information or conceals
material information, may be subject to criminal and civil penalties and PacificSource Administrators may cancel such
person’s membership and refuse to pay their claims.
*Employee Signature: ________________________________________________________ Date: ____________________
Employee: Please return the original to your employer and retain a copy for your records.
Employer: Please audit the form, retain a copy for your records, and forward a copy to PacificSource Administrators or submit a
spreadsheet electronically.
click to sign
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