Sample Salary Redirection/reduction Agreement Form (Page 2 of 2) in pdf

IMPORTANT INFORMATION REGARDING PARTICIPATION IN THE FLEXIBLE BENEFITS PLAN

I understand and agree to the following:

• Restrictions on Election Changes: On or after the first day of the plan year, I cannot change or revoke this Salary

Redirection Agreement with respect to pre-tax premiums before the next anniversary date of the plan unless a “change in

status” occurs (as defined under the Plan and the Internal Revenue Code), and the change is caused by and consistent

with the “change in status.”

• Commencement of Coverage and Status of Prior Elections: Execution of this Salary Redirection Agreement does not

begin coverage under the component benefit plans or insurance policies. The terms and conditions and actual coverage

effective date of the underlying coverage will be determined under the separate benefit plans or insurance policies. Prior

to the anniversary date each year, I will be offered the opportunity to add, drop or change coverage for the following plan

year. If I do not complete and return a new Salary Redirection Agreement form at that time, benefit plans or policies

currently in effect will continue. Elections under the Medical and Dependent Care FSA plans will not continue without my

completing and submitting a new Salary Redirection Agreement prior to the beginning of each plan year.

• Use of Personal Information: In addition to and without limiting in any way the rights my employer, the Plan, their

service provider and their respective agents, employees, subcontractors, and assigns may have under applicable state

or federal law or regulation, I hereby specifically authorize those parties to use my personal information (including, but

not limited to benefit elections, wages, employment status, number of dependents, marital status and health and

dependent child care information) as is reasonably required to administer the Plan (including evaluating and

processing requests for payment of claims) and detecting and preventing fraud or misrepresentation. I further authorize

my employer, the Plan, their service provider and their respective agents, employees, subcontractors and assigns to

further disclose any such personal information as is reasonably required for such purposes. I hereby expressly waive

and release any claims related to the use, disclosure or release of such information so long as the information is used

in furtherance of Plan administration or to detect or prevent fraud or misrepresentation.

• Effect of Pre-Tax Contributions on Benefits Payments: Paying for coverage on a pre-tax basis may cause insurance

claim payments under health and medical coverage to be subject to federal and state taxes if claim payments (combining

the total from all health and medical policies/plans) are in excess of medical expenses. Paying for disability income

policies with pre-tax premiums will cause the benefits payable thereunder to be taxable. Such coverages may be funded

on an after-tax basis to preserve the excludability of policy benefits.

• FOR MEDICAL AND DEPENDENT CARE FSA PARTICIPANT: I verify that I have received a summary of the tax rules,

operational guidelines and reimbursement procedures for use in Medical and Dependent Care FSA plans. I understand

the plan document will control notwithstanding any contrary oral representation by any person. I understand that

reimbursement will be available only for eligible expenses, and I agree to notify the employer if I receive reimbursement

for an expense that does not qualify. I also agree, upon demand, to indemnify and reimburse my employer for any liability

it may incur for failure to withhold taxes from any reimbursement I receive for non-qualified expenses, up to the amount of

additional tax owed by me. Furthermore, I understand that any account surplus at the end of the plan year shall be

retained by my employer and such amounts may (but are not required to) be used to offset administrative expenses or

future costs, and that the obligation to make reimbursements is the responsibility of my employer and not any service

provider hired by my employer to assist in processing claims. I understand that I may be responsible for a monthly

service fee for Medical and Dependent Care FSA plans and authorize my employer to payroll deduct any required

service fee amount. I acknowledge that in some cases reimbursement for eligible Medical and Dependent Care FSA

expenses may be administered through an electronic payment card (“the Card”) and agree to abide by the terms and

conditions of the Plan with regard to such card usage and the electronic payment cardholder agreement, including any

fees applicable to the Card, limitations as to Card usage, the Plan’s right to withhold and offset for ineligible claims, etc. I

also agree to use the Card exclusively for Medical and/or Dependent Care FSA expenses and to retain paper

documentation for any claims adjudicated by the Card.

Sample Salary Redirection/reduction Agreement Form Page 2

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