Asiflex Enrollment Agreement - 2017
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1Enrollment Agreement
2017 FSA Plan Year
I wish to have my salary redirected for the period
through June 30, 2017 in each of the
categories below. I understand the benefits available to me as well as the other rights and obligations that I have under the
Plan. I understand this agreement revokes any prior election under this plan and that during the above period this agreement
is irrevocable and cannot be changed except under special circumstances as outlined in the Summary Plan Description. This
agreement is subject to the terms of the Nevada System of Higher Education Flexible Spending Account Plan.
Name
_________________________________________________
NSHE Employee ID No:
(Last, First MI)
Street
_________________________________________________
Social Security Number:
City
NSHE-North Pay Org:
State, Zip
(DRI, GBC, TMCC, UCCSN, UNR, WNC)
Monthly
# of Months
Total for the
Not to
Deduction
Remaining
Plan Year
Exceed
Health Care Flexible Spending Account
Available to those enrolled in the HMO or CDHP PPO-HRA
_________ x
= _________
$2,550.00
Limited Purpose Flexible Spending Account
_________ x
= _________
$2,550.00
Available to those enrolled in the CDHP PPO-HSA
For vision or dental expenses only
Dependent Care Flexible Spending Account
_________ x
= _________
$5,000.00
(Daycare only max $416.66 per month)
How do you prefer ASIFlex to reimburse you for your claims?
Direct Deposit
Please use account information below to set up direct deposit (attach a voided check or copy of a check to this form)
Bank Name ______________
_____
9-digit bank routing number __ ______
________
Account number _____
_ ______
This is a
checking account or
savings account
If you choose to have your reimbursements deposited into your checking or savings account, how do you
prefer ASIFlex to notify you of the deposit?
Notify me by e-mail. My e-mail address is_____________________________
OR
Mail the notice to my home address.
Check: If you choose to receive reimbursement by check, select this box.
Mail a check to my home address.
By signing below, I acknowledge that either or both flexible spending accounts with ASI will cost $3.25 per participant per
month and will be deducted from my FSA balance.
Employee's signature: _________________________________________________
Date ______________
For further assistance contact ASIFlex: 1-800-659-3035
email:
RETURN THIS FORM TO YOUR EMPLOYEE BENEFITS OFFICE FOR PROCESSING
BCN-HR Benefits, M/S-0240
70 Artemesia Way
OR
FAX: (775) 784-4221
Room 2
RENO, NV 89557-0240
For Benefits Office Use Only:
Monthly or
Semi-monthly
Insurance plan selected:
PPO
HNHMO or
HTHMO
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