Fillable Basic Flex Employee Direct Deposit Enrollment Form printable pdf download

BASIC

FLEX

PLEASE PRINT CLEARLY TO ENSURE ACCURATE ENROLLMENT AND fUTURE COMMUNICATION.

Employer Name: __________________________________________________________________________________

Participant First Name: _________________________________ Last Name: _________________________________

Social Security #:

Date of Birth: _________ /_________ /__________

Address: _________________________________________________________________________________________

City, State, Zip: _________________________________________________ Phone Number: ____________________

E-mail Address: ______________________________________

(Notification of direct deposit payments are only sent via e-mail)

Pay Period: G Weekly G Semi-Monthly (twice a month) G Bi-Weekly (every other week) G Monthly

PREMIUM CONTRIBUTIONS

G I elect to participate (check all that apply)

EmployEr UsE

G Health Insurance G Group Life Insurance G Disability Insurance G Dental Insurance

Please complete for mid-

G HSA Contributions G Vision Insurance G Other(s)__________________________

year enrollments

The amount of salary reduction needed to pay premiums under the insured

Date of first deduction:

portions of the Plan will be determined by my employer.

_________________

G I elect NOT to participate

Eligibility date:

MEDICAL REIMBURSEMENT ACCOUNT

_________________

G I elect to participate (not to exceed employer limit of $_______________)

$ ____________ per pay x ______ (# of pays in plan year) = $ ____________ Annually (do not round)

Is this Medical Reimbursement Account a Limited Purpose Account (see page 6)

G I elect NOT to participate

DEPENDENT CARE ACCOUNT

G I elect to participate (not to exceed $5000 or $2500 if married filing separately)

$ ____________ per pay x ______ (# of pays in plan year) = $ ____________ Annually (do not round)

G I elect NOT to participate

DIRECT DEPOSIT (not all employers allow direct deposit as a reimbursement option)

G Use account information on file

G Use account information below

G No Direct Deposit

G Checking account OR G Savings account

ChECk ExAMPLE

A123456789 A0000123456 A1234

routing number

account number

check number

Financial Institution (name of bank): ________________________________________

Routing Number (always 9 digits):

Account Number: ______________________

I request that my periodic paychecks for the plan year be reduced on a pro rata pre-tax basis by the sum of my medical reimbursement, dependent care and premium contributions

to the plan, with such amount to be allocated among the benefits I selected above. I understand this election form cannot be revoked or changed during the plan year unless there

is a qualified change in status as defined in the Summary Plan description (SPd). I certify that I will only claim reimbursement for eligible expenses for myself and/or qualified

dependents as defined in the SPd. I further certify that these expenses will not be reimbursed under any other benefit plan. I understand any unused dollars remaining in my

account(s) at the end of the plan year will be forfeited. I have examined this agreement and to the best of my knowledge, it is true, correct and complete.

Employee Signature _____________________________________________________

Date ___________________

BASIC • 800.444.1922 • • 9246 PortAge InduStrIAl drIve • PortAge, mI 49024

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