"Health Reimbursement Arrangement (HRA) Enrollment Form - Payflex" - Alaska

Health Reimbursement Arrangement (HRA) Enrollment Form - Payflex is a legal document that was released by the Alaska Department of Administration - a government authority operating within Alaska.

Form Details:

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Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Alaska Department of Administration.

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Download "Health Reimbursement Arrangement (HRA) Enrollment Form - Payflex" - Alaska

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Health Reimbursement
Employer Must Fill In
Arrangement (HRA)
Re-enrollment
New
Change
Effective Date _____________________
Enrollment Form
1st Contribution Date _______________
Payroll Mode
W
B
S
M
Q
Division Code _____________________
(Be sure to print clearly, and provide all the information.)
A. Personal Information
Employer ID Number (Employer must fill-in)
Your Employer Name
Your First Name
MI
Last Name
Check if this address is new within the last year
Your Street Address
City
State
ZIP Code
Your Member Number (Social Security Number or employer assigned number)
Date of Birth (MM/DD/YYYY)
Date of Hire (MM/DD/YYYY)
(Prepared by the Employer)
B. Contribution Information
Re-enrollment
New Enrollment
Changed Enrollment
By signing this, you agree to the following statements:
• Based upon the IRS list of eligible expenses, the Plan Sponsor may choose which expenses will be covered by the plan.
• My employer makes all contributions to the plan as noted in the plan document.
• Depending on the plan document, I may carry over any amount remaining in my HRA to a new plan year.
• Reimbursements can’t exceed the contribution amount.
• This plan reimburses eligible expenses only after all my other plans have considered the expense.
(
If you’re enrolled in direct deposit already or don’t wish to enroll, you can ignore this section.)
C. Pre-Authorization for Direct Deposit
I authorize PayFlex Systems USA, Inc. to initiate a credit and/or debit entry to my account for my PayFlex
reimbursements.
This agreement is to remain in full effect until written notification is supplied by me to PayFlex terminating this agreement.
A “VOIDED” CHECK MUST ACCOMPANY DIRECT DEPOSIT APPLICATION
Employee Signature ____________________________________________________ Date __________________
Employer Signature ____________________________________________________ Date __________________
(PayFlex won’t process without the Employer Signature)
PayFlex cannot and shall not provide any payment or service in violation of any United States (US) economic or trade sanctions.
Please return completed form to:
Division of Retirement and Benefits
P.O. Box 110203
Juneau, AK 99811-0203
Phone: (800) 821-2251 or (907) 465-4460
Fax: (907) 465-3086
Health Reimbursement
Employer Must Fill In
Arrangement (HRA)
Re-enrollment
New
Change
Effective Date _____________________
Enrollment Form
1st Contribution Date _______________
Payroll Mode
W
B
S
M
Q
Division Code _____________________
(Be sure to print clearly, and provide all the information.)
A. Personal Information
Employer ID Number (Employer must fill-in)
Your Employer Name
Your First Name
MI
Last Name
Check if this address is new within the last year
Your Street Address
City
State
ZIP Code
Your Member Number (Social Security Number or employer assigned number)
Date of Birth (MM/DD/YYYY)
Date of Hire (MM/DD/YYYY)
(Prepared by the Employer)
B. Contribution Information
Re-enrollment
New Enrollment
Changed Enrollment
By signing this, you agree to the following statements:
• Based upon the IRS list of eligible expenses, the Plan Sponsor may choose which expenses will be covered by the plan.
• My employer makes all contributions to the plan as noted in the plan document.
• Depending on the plan document, I may carry over any amount remaining in my HRA to a new plan year.
• Reimbursements can’t exceed the contribution amount.
• This plan reimburses eligible expenses only after all my other plans have considered the expense.
(
If you’re enrolled in direct deposit already or don’t wish to enroll, you can ignore this section.)
C. Pre-Authorization for Direct Deposit
I authorize PayFlex Systems USA, Inc. to initiate a credit and/or debit entry to my account for my PayFlex
reimbursements.
This agreement is to remain in full effect until written notification is supplied by me to PayFlex terminating this agreement.
A “VOIDED” CHECK MUST ACCOMPANY DIRECT DEPOSIT APPLICATION
Employee Signature ____________________________________________________ Date __________________
Employer Signature ____________________________________________________ Date __________________
(PayFlex won’t process without the Employer Signature)
PayFlex cannot and shall not provide any payment or service in violation of any United States (US) economic or trade sanctions.
Please return completed form to:
Division of Retirement and Benefits
P.O. Box 110203
Juneau, AK 99811-0203
Phone: (800) 821-2251 or (907) 465-4460
Fax: (907) 465-3086