"Employee Direct Deposit Enrollment Form - Basic Flex"

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Download "Employee Direct Deposit Enrollment Form - Basic Flex"

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BASIC
FLEX
PLEASE PRINT CLEARLY TO ENSURE ACCURATE ENROLLMENT AND fUTURE COMMUNICATION.
Employer Name: __________________________________________________________________________________
Participant First Name: _________________________________ Last Name: _________________________________
-
-
Social Security #:
Date of Birth: _________ /_________ /__________
Address: _________________________________________________________________________________________
City, State, Zip: _________________________________________________ Phone Number: ____________________
E-mail Address: ______________________________________
(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.
Employee Signature _____________________________________________________
Date ___________________
BASIC • 800.444.1922 • www.BASIConlIne.Com • 9246 PortAge InduStrIAl drIve • PortAge, mI 49024
RV8/12
BASIC
FLEX
PLEASE PRINT CLEARLY TO ENSURE ACCURATE ENROLLMENT AND fUTURE COMMUNICATION.
Employer Name: __________________________________________________________________________________
Participant First Name: _________________________________ Last Name: _________________________________
-
-
Social Security #:
Date of Birth: _________ /_________ /__________
Address: _________________________________________________________________________________________
City, State, Zip: _________________________________________________ Phone Number: ____________________
E-mail Address: ______________________________________
(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.
Employee Signature _____________________________________________________
Date ___________________
BASIC • 800.444.1922 • www.BASIConlIne.Com • 9246 PortAge InduStrIAl drIve • PortAge, mI 49024
RV8/12