Wells Fargo - Flexible Benefits Plan Election Form / Salary Reduction Agreement (Page 2 of 3) in pdf

Terms and Conditions

I hereby authorize the above payroll reductions as my contribution to my Employer’s Flexible Benefits Plan.

I understand that:

•

Changes in the Flexible Benefits Plan elections can only be made at the end of the plan year unless due to and

consistent with a valid change in status (e.g. change in legal marital status; change in number of dependents;

change in employment status; dependent satisfies or ceases to satisfy dependent requirement; residence change),

cost or coverage changes, and such other events as would permit a revocation or change of election under IRC

125 regulations. Participation in this plan will automatically cease upon termination of employment. In most cases

NO change may be made in the Medical Expense Reimbursement Account except for termination of participation

due to termination of employment. For special rules affecting your plan, please contact your employer. FICA taxes

are not paid on Sec. 125 salary reduction; therefore, social security benefits at retirement may be reduced.

•

Execution of this benefit election/salary reduction agreement does not automatically institute insurance coverage; in

most instances an application for insurance must be completed. Premiums charged for insurance coverage may be

adjusted by the insurance carrier issuing the contract and my “take-home” pay may be higher or lower depending

on the selections made.

•

This authorization replaces any previous authorization I have made.

FLEXIBLE BENEFIT PLAN

EXPENSE REIMBURSEMENT RULES FOR PARTICIPATION

READ THE INFORMATION PROVIDED BELOW AND I UNDERSTAND THE RULES FOR PARTICIPATION IN THE EXPENSE

REIMBURSEMENT PORTION OF THE FLEXIBLE BENEFIT PLAN.

•

I understand that if the dollars allocated to be reimbursed to me under the provisions of this plan are not used for

such benefits, the balance of the unused amounts must be forfeited to my Employer (“use it or lose it”). Unused

amounts cannot be carried forward into the next plan year.

•

Medical expenses reimbursed under this plan are not eligible as tax deductions on my federal income tax return.

•

Medical expenses for reimbursement include certain expenses incurred during the plan year for the diagnosis, cure,

mitigation, treatment, or prevention of disease for which there has been no other reimbursement through insurance,

damages, or otherwise. Certain cosmetic surgery expenses and medical insurance premiums are not eligible for

reimbursement.

•

In most cases, no change may be made in the medical expense reimbursement account except for termination of

the plan due to termination of my employment. For special rules affecting your plan, please contact you employer.

I understand that during an unpaid leave of absence, contributions to the medical expense reimbursement account

must continue, just like insurance premiums. For payment options, contact your employer.

•

If I terminate my employment and do not elect to continue my medical expense account payments on an after tax

basis, only expenses incurred during the period of coverage will be reimbursed. Coverage under the

reimbursement account ceases when the payments cease.

•

Dependent care expenses reimbursed under this plan are not eligible for the dependent care tax credit on my

federal income tax return. Dependent care elections are irrevocable for the period of coverage, except for a change

in status, or other qualified event, which affects your need for day care.

•

Dependent care expenses eligible for reimbursement must be provided by third parties meeting both applicable

state law requirements and federal tax law requirements. Claims may only be made for dependent care that has

already been provided. Amounts allocated to the dependent care reimbursement fund cannot exceed the lesser of

the amount allowed be federal tax law or $5,000 for the calendar year.

•

I understand that I will receive expense vouchers to assist in filing for the expense reimbursement and in keeping

track of eligible expenses under the plan. I also understand that I must complete one of these vouchers and submit

it with proper documentation in order to be reimbursed for any expenses on a timely basis.

•

I understand that I must submit documentation as requested by Wells Fargo for all expenses reimbursed under this

plan.

•

I agree to notify my Employer if there is reason to believe that any item for which reimbursement has been made is

not allowable under the terms of the Plan.

Wells Fargo - Flexible Benefits Plan Election Form / Salary Reduction Agreement Page 2

Related Articles

Related forms

Related Categories