(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
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.
(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
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.
Pressing the PRINT button will only print the current page. Download the document to your desktop, tablet or smartphone to be able to print it out in full.