FSA Enrollment

Benefit Elections
Group Insurance Premiums
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If you participate in your employer’s insurance plan(s), your premiums will automatically be deducted on a pre-tax basis unless you notify your Human Resource or Personnel Department.

Flexible Spending Accounts
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The IRS regulations state four conditions: 1) Any expenses you incur must be within the plan year; 2) Any expenses you incur must not be covered by any other source, such as insurance; 3) You must provide proper documentation to receive payment; 4) You cannot change or revoke your elections during the plan year unless there is a specific change in status and your employer allows such changes.
Medical Flexible Spending Amount*
(Annual Amount)
Dependent Care Account*
(Annual Amount)
*By participating in a Flexible Spending Account you will receive a Benefits Card. By using the benefits card, you certify that each time the card is used, it will be used only for Qualified purchases as described in the cardholder agreement, and you have not received or will not see reimbursement for any expenses paid with the card from any other benefit source. This card may not be used at all merchants that accept Visa debit Cards.

List Name & DOB (click plus symbol to add additional names)

First Name	M.I.	Last Name	DOB

Direct Deposit Information / Bank Account Information (NOT REQUIRED)
I authorize Consolidated Admin Services to initiate a credit and/or debit entry to my account for my plan reimbursements. This agreement is to remain in full effect until written notification is supplied by me to CAS terminating this agreement. A voided check must accompany enrollment form. Do not use a deposit slip as the number could be available.
Bank Name
Account Number
Routing Number

Election Information
Please select option:*
- Yes, I wish to participate in the flexible spending account plan and authorize payroll reduction from my salary on a pre-tax basis in the amount(s) indicated below, and continuing until this election is amended or terminated or until the Plan Year ends. Employer-sponsored benefit coverage contributions are automatically reduced from my compensation on a pre-tax basis.
- No, I have been offered the opportunity to enroll in the flexible spending account plan and do not wish to enroll at this time. However, my employer-sponsored benefit coverage contributions are automatically reduced from my compensation on a pre-tax basis.
Type Signature*
Today's Date*
MM slash DD slash YYYY

Employee Information