Flexible Spending Account Enrollment Form - Lifetime
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2Flexible Spending Account
Enrollment Form
Employer Name: ____________________________________________________________________________
Participant Name (First, MI, Last): ______________________________________________________________
Social Security Number: ______ - ______ - ____________ Phone Number (________) _________________
Address: ___________________________________________________________________________________
City, ST, ZIP: ________________________________________________________________________________
Date of Birth: _______/________/___________
Date of Hire: _______/________/___________
Email Address: ___________________________________________________
FSA Benefit Election
Per Pay Period Amount
Total Annual Amount
# Pays Per Year
$
$
Health Care Election—Standard
$
$
Health Care Election—Limited
$
$
Dependent Care Election
Carrier Information
.
Check the boxes if you are enrolled in any of these benefits through your employer. Medical; Dental; Vision; Rx
Automated Claims Transfer: If you are eligible for ACT (check with your Employer), certain expenses submitted through your
insurance provider may automatically be reimbursed to you, unless you or any of your dependents have Coordination of Bene-
fits (COB) with other Plans. This feature is not applicable to Health Spending Card holders.
I do not want ACT or I have COB and am not eligible for ACT.
Spouse/Dependent Information (Attach additional pages if necessary)
I do not have a spouse or dependents
Name
Social Security Number
Date of Birth
Gender
Relationship
Direct Deposit Election (Complete this section if you want Direct Deposit of your reimbursements)
Type of Account (Check one):
Checking
Savings
Name of Bank: _____________________________________________________________________________
Transit ABA Routing #: ___________________________ Account #: ________________________________
Participant Authorization—
Return signed form to your Employer.
By signing below I agree to participate in my employer’s pre-tax program and certify that I understand and will comply
with the regulations governing such Plan. I understand the basic provisions provided on page 2 of this form are guide-
lines only and that my Plan’s Summary Plan Descriptions prevails.
Participant Signature: ______________________________________________________ Date: _________________
To Be Completed by the Employer
New Hire
Open Enrollment
Effective Date: _____________
This Plan has employer funded money:
Yes
No. If Yes,
First Payroll Deduction Date: __________________
ER Money:
Payroll Based?
Annual Amount
Notify Payroll of deduction amount and date
$
Health Care
Yes
No
Keep copy of Enrollment Form for your records
$
Dependent Care
Yes
No
Forward copy of Enrollment Form or provide data on a file to
Lifetime Benefit Solutions
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