PLEASE PRINT. All information is required or your enrollment cannot be processed.
Employer _______________________________________________________ Social Security Number
Employee Name (First, Last)
Date of Birth (MM-DD-YYYY) Date Hired (MM-DD-YYYY)
Home (Street) Address APT.
City
State Zip
Home Phone Email _______________________________________________________________
By enrolling in the plan you will receive a take care® Flex Benefits Card to pay for qualified plan expenses. If you would also like to receive a
Card for your spouse or dependent (age 18 years or older) you may do so by logging into your account at www.takecareWageWorks.com.
Employer to complete or enrollment cannot be processed.
Plan year start
(MM/DD/YY) / / and end / / . First payroll start date / / .
No. of Pays
. Dept. .
OPTION 1
Healthcare Account
YES I elect to contribute $
(before taxes) for the PLAN YEAR, which is $
per pay period to fund my account that pays
qualied out-of-pocket healthcare expenses that are not covered by my employer’s health plan or any other health plan
.
NO I decline this option for this plan year and understand that I will lose all tax savings that I could receive as a participant.
OPTION 2
Dependent Care Account
This pays for day care expenses for a dependent child, adult or elder, so that you may work. Eligible services include: nursery school, nanny, before
and after school care through age 12, day care for a disabled adult or child, elder day care for parent or dependent, day camp through age 12.
YES I elect to contribute $
(before taxes) for the Plan Year, which is $
per pay period to fund my account that pays
qualied dependent daycare or elder care expenses.
NO I decline this option for this plan year and understand that I will lose all tax savings that I could receive as a participant.
OPTION 3
Agreement to Save Taxes on Insurance Premiums
YES On the appropriate benet enrollment form, I have enrolled in certain employer-sponsored insurance benets (i.e. health insurance).
I understand that my share of the premium for these employee benets will automatically be paid with pre-tax dollars. I also
understand that if my required contributions for these insurance benets are increased or decreased while this agreement is in
eect, my taxable income will automatically be adjusted to reect that change.
NO I decline this option for this plan year and understand that I will lose all tax savings that I could receive as a participant.
OPTION 4
Additional Benefit (please insert description provided by your HR department, if applicable)
__________________________________________________________________________________________________________________________
YES I elect to contribute $
(before taxes) for the Plan Year, which is $
per pay period for funding reimbursement of
this additional benet outlined by my HR department.
NO I decline this option for this plan year and understand that I will lose all tax savings that I could receive as a participant.
IMPORTANT: Please read the following before signing this enrollment form. My employer and I agree that my taxable income will be reduced each pay period during the year by an
equal portion of the benet elections set forth above and that qualied expenses will be paid on a tax-free basis. I understand that I may change my election in the event of certain
changes in my status and that, prior to the rst day of each plan year, I will be oered the opportunity to change my benet election for the upcoming plan year. I acknowledge
that I have received, read, and understand the Summary Plan Description. I understand that the take care® Card is available to pay only qualied expenses and that qualied
expenses paid with the Card cannot be reimbursed by any other plan and that I will not seek reimbursement for expenses paid with the Card from any other source. I understand
that when using the take care® Card I must keep all receipts and that, on occasion, I may be asked for documentation of charges made with my Card. I also understand that if a
payment is made that is not for qualied expenses, I will repay my employer. For any expenses not repaid by me, I authorize my employer to deduct the amount from my paycheck
(if permitted by state law).
Employee signature ________________________________________________________________ Date __________________________________
Return completed form to your employer.
© 2014-2017 WageWorks, Inc. All rights reserved. 3593 (201706)
take care
®
Flex Benets Plan
Enrollment Form
