Allied Benefit Systems, Inc.
P 800.288.2078
200 West Adams, Suite 500
F
Chicago, IL 60606
E eligibility@alliedbenefit.com
Employee SSN Date of Birth
Address City State Zip
Divided
By
Equals
/ =
/ =
/ =
Employee Signature Date
Employee Signature Date
Female
Male
Employer Location (if applicable)
Effective Date
Employer Name
Group Number
Payroll Cycle
I certify the above information is true and correct and I authorize any premiums and HSA contributions, if applicable, to be paid on a pre-tax basis
pursuant to Internal Revenue Code Section 125. I understand that any amounts which are not used for eligible expenses incurred during the Plan Year
or Grace Period, will be forfeited in accordance with current Plan pro-visions and tax laws. I further understand that the salary reduction(s) will be in
effect for the Plan Year and cannot be revoked except as authorized by current Plan provisions and laws.
IF YOU DECLINE PARTICIPATION: The benefits of the plan have been thoroughly explained to me and I decline participation.
Employer Use Only (Required for processing)
Employee's Flex Plan Effective Date
First Payroll Date
SECTION D- Direct Deposit
If yes, please complete the attached "Flex Direct Deposit
Enrollment Form" and include a voided check.
NO
YES
I am currently participating in direct deposit. Please keep current banking information on file.
Dependent Name:
Date of Birth:
SSN:
SSN:
SSN:
Please complete the information below for all dependents who should have an Allied Flex Debit Card.
$2,650.00
SECTION C - Allied Flex Debit Card - SSN and DOB are quired. Dependent must be over 17.
Dependent Name:
Date of Birth:
24
Example $110.42
(Plan Year Example)
$
I elect to participate in the Dependent Care
Account
Use the table below to select your Flex benefits. The option for Limited Purpose Flex (LPFSA) is only available to employees participating in a
HDHP plan. Please note that if you elect participation in the LPFSA below, you may elect to participate in the DCA but not the FSA.
Deduction from each pay period
Flexible Spending Account Enrollment Form
Annual/Mid-Year
Election Pledge
Employee Gender
Daytime Phone
# of Pay Periods:
Annually / Mid-Year
Employee Name
Employee Email Address
$
SECTION E - EMPLOYEE CERTIFICATION
I would like to participate in Direct Deposit:
Spouse Name:
Date of Birth:
Dependent Name:
Date of Birth:
SSN:
312.906.8879
I elect to participate in the Health Flexible
Spending Account
SECTION A - EMPLOYER/EMPLOYEE INFORMATION
SECTION B - Election(s)
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome