fsa enrollment form · fsa enrollment form employee information (please print clearly.) ... i also...

00094-02-0810 © 2010 eflexgroup, Inc.

FSA Enrollment Form

Employee Information (Please print clearly.)Social Security # __________________________________________________ Date of Birth ________________________________________

Employer Name __________________________________________________ Dept/Location _______________________________________

First Name ___________________________________ Middle Initial _________ Last Name _________________________________________

Employee Home Address ______________________________________________________________________________________________

City ___________________________________________________ State ________________ Zip Code ________________________________

Home Phone # __________________________________________ email _______________________________________________________ Help us go green! If provided, we’ll use your email as our primary method of contact.

Employment Date __________________________________________ Plan Effective Date __________________________________________ Month Day Year Month Day Year

Employer Information (Employer to complete the information below.)

Date of 1st Payroll Deduction ______________________________________________________ � 12-Month Plan Year Month Day Year

Employee Plan Effective Date _____________________________________________________ � Short Plan Year Month Day Year

Employee Elections (Employee to complete the information below) A. Group Medical Premiums (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.) Annual Election # of Payroll Deductions $ Per Pay Check

B. Health FSA $ ________________________ / _____________________ = $ _________________________ Employer Contribution $ ________________________ / _____________________ = $ _________________________

C. Dependent Daycare FSA $ ________________________ / _____________________ = $ _________________________ Employer Contribution $ ________________________ / _____________________ = $ _________________________

D. Individual Health Policy $ ________________________ / _____________________ = $ _________________________ Employer Contribution $ ________________________ / _____________________ = $ _________________________

E. Limited Purpose FSA $ ________________________ / _____________________ = $ _________________________ Employer Contribution $ ________________________ / _____________________ = $ _________________________

F. Administration Fee (if any) $ ________________________ / _____________________ = $ _________________________ TOTALS $ ________________________ / _____________________ = $ _________________________

� My employer offers the claims auto download through my medical carrier. I would like to take advantage of this service.

� No, I do not want to enroll. If a change in status occurs, I may have the right to enroll in the plan at that time (if my employer’s plan allows). � Yes, I want to enroll. 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. Please see the Summary Plan Description for details.

Signature ________________________________________________________________________ Date ______________________________

00094-02-0810 © 2010 eflexgroup, Inc.

Direct Deposit Information (Please complete this section if you are a new eflex customer or if your bank account information has changed in the past year. You don’t need to complete this section if you had direct deposit in the last plan year and your bank account information hasn’t changed.)

Employee Information

Employee Name: ______________________________________ Social Security Number: _______________________________

Home Telephone: ______________________________________ Alternate Telephone (work/cell): _________________________

Address: ________________________________________________________________________________________________

City: _________________________________________________ State: ______________ Zip: ____________________________

Email address: ________________________________________ Name of Employer: ___________________________________

Bank Account Information

Bank Name: ______________________________________________________________________________________________

Bank Address: ____________________________________________________________________________________________

City: ____________________________________________________ State: __________ ZIP: ____________________________

Name on the Account: ____________________________________________

Routing and Transit Number: _______________________________________

Account Number: ________________________________________________

IMPORTANT: Please provide a voided check for each account listed above. We will not process without a voided check. Do not use a deposit slip as the number could be invalid.

AuthorizationI authorize reimbursements from my Section 125 FSA, Dependent FSA, Individual Health Premium, Limited Purpose FSA, or my Section 105 Health Reimbursement Arrangement to be sent to the financial institution named above to be deposited in the designated account.

In the event funds are deposited erroneously into my account, I authorize my Section 125/105 administrator to debit my account(s)not to exceed the original amount of the credit.

I also understand that all direct deposits are made through the automated clearing house (ACH), and that funds availability is subject to the terms and limitations of the ACH as well as my financial institution.

Signature: _________________________________________________________________ Date: _________________________

Please fax, email, or mail completed form with a voided check to your HR/Personnel Department.

2740 Ski Lane · Madison, WI 53713 Phone: 877.933.3539 · Fax: 877.231.1287

www.eflexgroup.com

Don’t Forget! ��

��

��

��

��

�� !��

�� !��"��

�� #��"��$��

�%��"� ��&��$'#�� ()*+�� "��"��+�*��&��!��&��"��+��(��,� ��"��+��+��+��

You have choices

© 2010 eflexgroup, Inc. · 2740 Ski Lane · Madison, WI 53713 · Phone: 877.933.3539 · Fax: 877.231.128700016-02-0810 www.eflexgroup.com

Frequently Asked QuestionsQ: Am I able to make adjustments to my eflex Flexible Spending Account (FSA) during the plan year, i.e. adjust my account election or enroll in another account such as Dependent FSA?

A: Changes to your eflexFSA account, including changing your annual election, can only be made if there is a qualified change of status. The IRS determines what’s considered a qualified change of status. Examples of qualified changes in status include: birth, death, divorce, or marriage. For more information on IRS status changes, please visit the IRS website at http://www.irs.gov/publications/p969/ar02.html

Q: What if I incur a large expense at the beginning of the plan year that will use funds I don’t yet have available in my eflexFSA?

A: If the claimed expense is for your Health FSA, we’ll pay the entire claim up to your maximum annual election. Your payroll deductions will continue throughout the plan year, even though the funds have already been spent. Dependent FSA accounts and Individual Premium Accounts are reimbursed differently; you’re only eligible to receive funds as they become available until you reach your maximum annual election.

Q: What if I make a purchase for an amount over the available balance in my eflex FSA account?

A: It is important to remember that the amount you have available in your eflexFSA account is your available balance on the eflex Card. You may use the eflex Card up to this amount, but never over. If you make a purchase for an amount over your available balance, the entire purchase will be denied. For example, if you have $75 in your account, and you try to make a purchase for $100, the entire transaction will be denied. If you know your available balance ahead of time, you can ask the store clerk to run your card for that amount and then use another form of payment to cover the rest. For this reason, it is recommended that you check your account balance frequently. For your convenience, you can check your account balance 24-hours a day at www.eflexgroup.com

Q: If for any reason my employment is terminated during the plan year, am I allowed to claim expenses incurred through the remainder of the plan year?

A: If you terminate your employment, your plan ends on your last date of employment. You will only be able to submit claims incurred prior to your date of termination.

Q: What’s the best way to determine how much to elect for my eflexFSA? Is there a minimum or maximum that I’m allowed to elect?

A: One way to determine how much to elect for your eflexFSA is to review your check registers, end-of-year credit card statements or receipts from the previous year. This process will help you to determine how much you’ve spent on eligible FSA expenses. You may also use our planning worksheet to determine your election amount. The maximum election amount for your eflexFSA is determined by your employer and can be found in your Summary Plan Description. The maximum election for the Dependent FSA is $5,000 for head of household or married couples filing joint tax returns. It’s $2,500 for married couples filing separate tax returns.

Q: If I’m the primary, can I be reimbursed for my spouse’s out-of-pocket medical expenses, too?

A: If you have a Health FSA, you can be reimbursed for medical expenses incurred by you, your spouse, and your tax dependents.

Q: My spouse and I both work for the same company and both participate in the FSA, can we submit for each other’s services?

Frequ

© 2010 eflexgroup, Inc. · 2740 Ski Lane · Madison, WI 53713 · Phone: 877.933.3539 · Fax: 877.231.128700016-02-0810 www.eflexgroup.com

A: Yes. Because you’re both enrolled in the eflexFSA, you may submit claims on each other’s account.

Q: Do you offer direct deposit for claims payments?

A: Yes. Direct deposit is our preferred method of payment. You’ll receive payments by direct deposit faster and cut down on costs and paper use as well. Direct deposit sign-up forms can be found under the Forms section on our website.

Q: What’s the process for submitting documentation after I have used my eflex card? Do I always have to submit documentation? What do I do if I have lost my documentation?

A: There will be times when we’ll require a receipt for claim substantiation to comply with the IRS guidelines even for debit card purchases. Your receipt must include the date of service, the dollar amount, and a description of service. A credit card receipt will not meet IRS substantiation requirements. Therefore, we advise all eflex Card users to keep their receipts just in case we ask for them to comply with the IRS.

If we do need a receipt for an eflex Card purchase, we’ll send out three notices. If we don't receive the receipt after 30 days, we'll have to temporarily deactivate the card until we receive substantiation. Make sure eflex has your current email address. If we do need a receipt for a debit card purchase, we’ll send you an email the day we receive your claim or the debit purchase is made. Email is the fastest way to be notified and will give you the most time if you need to track down a receipt. Documentation can be sent to us via fax, email, or mail.

Many major retail outlets are now required to code their registers to identify and approve flex-eligible items at the point of purchase. In most cases, we’ll no longer ask for receipts eligible flex purchases as long as you shop at an approved location. Please visit www.sig-is.org for the most current IIAS list of participating stores.

In most cases, if you’ve lost documentation for an eflex Card purchase, you can contact the vendor for a reprint of your receipt.

Q: Where can I find a list of eligible eflexFSA expenses?

A: You can find a summary of eligible expenses on our Employee Worksheet under the Forms section of our website. There is also a list on the back of your eflexFSA brochure.

Q: How long will it take for my claims to be processed and reimbursed once they have been submitted to eflex?

A: All of our claims are touched within 30 minutes of our receipt. Claims are typically processed within 1-2 business days.

Q: How do I get reimbursed for my expenses?

A: To be reimbursed for your medical expenses, you’ll need to submit a claim form and documentation. Claim forms can be found on our website under the Forms section. Once you’ve completed the form, attach the documentation and send it to us via fax, email, or mail. You may also file your claims electronically through your eflex online account at https://employee.eflexgroup.com. Follow the instructions given on the page to access your account.

Q: What happens to unused funds in my FSA plan?

A: At the end of the plan year, they’re returned to your employer as forfeiture.

How to Avoid the Most Common Mistakes in Debit Card Purchases

00090-02-0810

Questions about your efl ex Card or any other aspect of your efl ex plan? • Call us at 1.877.933.3539 • Email to CustomerCare@efl exgroup.com • Chat with the Flexpert at efl exgroup.com

2740 Ski Lane • Madison, WI 53713ph: 1.877.933.3539 • fx: 1.877.231.1287

www.efl exgroup.com

The efl ex Card makes it easy to access your pre-tax dollars. Just swipe it like you would any credit card when you make a covered purchase. We’ll take care of paying the provider and deducting the money from your efl ex balance. There are no transaction fees or pin numbers for you to remember.

Here are a few things you can do to get the best value from your efl ex Card:

• Use the card at merchants that have the IIAS (Information Identifi cation Approval System). Many major retail outlets, particularly pharmacies, are required to automatically identify and approve fl ex-eligible items at the point of purchase. In most cases, we won’t have to ask for receipts for over the counter purchases as long as you shop at an approved location. Please visit efl exgroup.com/forms to see a list of IIAS merchants.

• Use your card at any medical provider, clinic, hospital, vision center, dentist, IIAS or 90% Rule participating pharmacy. (Sorry, it won’t work at a restaurant, ATM, or service station.)

• If we request documentation for an efl ex Card purchase: •Send an itemized bill or an Explanation of Benefi ts (EOB) from your insurance carrier. We can’t process your claim from a credit card slip because it doesn’t show all of the required information. At a minimum, we need the date of service, a description of the service, the service provider, and the amount charged.

•Don’t send a statement showing “Balance Forward.” The IRS says we need documentation showing the type and nature

of service, the date of the service, and the amount of the charge. A balance-forward statement usually shows only the dollar amount so it doesn’t meet IRS requirements.

• Use your efl ex Card to pay for services you receive in the current plan year, not the previous plan year. Your plan year and the date of the service (not billing date) must coincide. For example, if your plan runs the calendar year (i.e., January through December), service must occur between January 1 and December 31. (If your plan includes the 2.5-month extension, you’ll have until March 15.) According to the IRS, eligible expenses are based on the date of service regardless of when you receive or pay the bill.

• Purchase only eligible items with your efl ex Card. There are still a few locations that aren’t in full compliance with IIAS. In these locations, you may be able to purchase ineligible items (like vitamins and supplements). However, we request documentation for items you purchase from non-IIAS merchants. When you submit documentation showing that you purchased ineligible items, we’ll deny coverage and request repayment to your account unless you can provide a valid written letter of medical necessity that is signed by your physician. Note: A valid letter of medical necessity will confi rm that the supplement is required to treat a specifi c medical condition. Please ensure it also includes your fi rst and last name along with the last four digits of your Social Security Number. Send the original signed letter of medical necessity along with copies of your receipts and any other documentation to efl ex.

• Remember to check your efl exFSA acccount balance regularly at efl exgroup.com. You may use your efl ex Card up to the available balance, but never over. If you make a purchase for an amount over the available balance, the entire purchase will be denied. For example, if you have $75 in your account and you try to make a purchase for $100, the entire transaction will be denied. By knowing your available balance ahead of time, you can ask the store clerk to run your card for that amount and then use another form of payment to cover the rest.

Flexible Spending Account (FSA) Bene� ts at a Glance

Premium Only Plan

Health FSA

Using your FSA is easy! Just swipe your e� ex Card like you would a credit card at the � me of purchase to pay the

provider with funds from your FSA .The e� ex Card can be used at eligible

daycare centers, doctor/dental o� ces, clinics,

vision centers, and pharmacies.

FSAs help to � ll coverage gaps between

health plans and out-of-pocket expenses.

eflexFSA

It doesn’t ma� er what you call them–Cafeteria Plans, Sec� on 125 Plans, Flex Plans, or FSAs—they save you money by lowering your taxable income. Developed under IRS Sec� on 125, an FSA allows you to pay for certain health and dependent care expenses with pre-tax dollars. You won’t pay income taxes on the funds you put into your FSA because they’re deducted before taxes are calculated. That’s a savings of 28% for many people. Par� cipa� ng in the FSA is like giving yourself a raise.

To get started, simply select an amount of money to be taken gradually from each paycheck throughout the year to be put into your FSA. We recommend you use our handy Personal Planning Worksheet to plan your expenses. You may download a Planning Worksheet at e� exgroup.com/forms.

There are three di� erent types of FSA plans: Premium Only Plans, Health FSA, and Dependent Care FSA.

The por� on of the insurance premiums you pay for group health plan coverage can be deducted from your payroll on a pre-tax basis. You’ll be automa� cally enrolled in this plan.

This plan pays for out-of-pocket medical expenses incurred during the plan year.

Maximum Contribu� on. The maximum amount you can contribute per year is: $• _______________ . This amount is referred to as your “annual elec� on.”

Uniform Coverage Rule. Your full annual elec� on amount is available at the start of the plan year, even • though you have not yet contributed the full amount. You can’t, however, spend more than the annual elec� on amount.

Examples of What’s Covered

Acupuncture Alcoholism and drug addic� on treatmentAmbulance BandagesCare for handicapped Contact lens & supplies Deduc� bles Dental co-pays and deduc� bles Dental services (non-cosme� c) and X-rays Diabe� c supplies/insulin Doctor o� ce visit co-pays Eligible hospital charges (not covered by insurance)Eye glasses Guide dog careHearing-aid ba� eries Holis� c healing services (medically necessary), Lab fees Laser eye surgery Learning disabili� es care Medical miles (per IRS limits) Oral Surgery Orthodon� a Prescrip� on drugs and co-pays Prostheses Rou� ne physicals Vision exams and X-rays Wheelchairs) X-Rays

Examples of What’s Not Covered

Birthing classes Breast pumpsDental bleaching or bonding Diapers/diaper serviceDeodorants Electrolysis Health club dues Feminine hygiene products Hair removal products Marital or family counselingMassage therapy Meals, excluding inpa� ent careNon-prescrip� on vitamins Over-the counter medica� ons without a prescrip� onVitamins/Supplements Whirlpools

Note: These are examples of eligible and ineligible expenses according to the IRS. This list is not all inclusive. Please visit e� exgroup.com/forms/FSA for a more complete list or call 877.933.3539 if you have ques� ons about a certain expense.

The DC FSA covers daycare expenses for children up to the age of 13, and for elder dependents (like aging parents) that live in your home. It also covers a spouse or dependent that is physically or mentally challenged for whom you claim an exemp� on. To par� cipate in the DC FSA, you and your spouse must work or a� end school full � me. Please note that if you’re divorced or separated, the IRS only considers the custodial parent or guardian (the one who has custody 50% of the � me) eligible for this account.

Maximum Contribu� on. The maximum amount you can contribute per year is: $5,000 for married • couples � ling jointly and singles. If you’re married and � ling separately, you may elect up to $2,500 per year. You can only spend funds that have accrued in your account; there is no uniform coverage rule.• Care must be from a quali� ed provider with a valid Social Security Number (SSN) or tax ID • May only be used for eligible “employment related” expenses (expenses incurred in order for you • and/or your spouse to be employed).

Recurring claims op� on allows you to submit your claim and documenta� on only once a year.

Examples of Covered DC FSA Expenses Examples of DC FSA Expenses Not Covered

Babysi� ersDay-care centersElder careDay campsPreschoolA� er-school careNanny/Au Pair

DiapersEduca� onal expenses, including KindergartenFood, snacks, and mealsIncidental fees, such as ac� vity fees, � eld tripsOvernight camps

Note: These are examples of eligible and ineligible expenses according to the IRS. This list is not all inclusive. Please visit e� exgroup.com/form/FSAs for a more complete list or call 877.933.3539 if you have ques� ons about a certain expense.

IRS Rules that Apply to FSAs:Change of Status. Coverage con� nues for the full plan year. You can’t change your elec� on or drop out • of the plan unless you’re no longer employed or you experience a quali� ed change of status event, such as a marriage or divorce. Use It or Lose It Rule. You’re responsible for using all of the funds in your FSA during the plan year. If • any remaining balances are not claimed within 90 days of the plan year-end date, they are forfeited to the employer. So, be sure to plan carefully!You can’t transfer funds from your Health FSA into your DC FSA or vice versa.• Services must be incurred within the plan year. •

Our easy-to-use online enrollment process lets you see your tax savings as you’re planning your contribu� on amounts. You can then use your debit card for instant access to your FSA funds or submit a claim for reimbursement one of � ve easy ways:

• Online via our secure web form at e� exgroup.com (requires account login)• Email via secure ZixMail• FAX via our secure FAX system• Postal Mail• Through the e� ex Mobile app if you have an iPhone or Android

Claims for FSAs are typically processed within just two business days. Be sure to sign up for direct deposit; it’s the fastest and most environmentally friendly means of reimbursement. Plus, with our secure web and mobile portals, you can see your balance, view statements, check claims status, and upload receipts any � me of the day or night.

Dependent Care FSA

The Fine Print

2740 Ski Lane | Madison, WI 53713 | p: 877.933.3539 | f: 877.231.1287 | e: customercare@e� exgroup.com | e� exgroup.com

e

Get Started

The DC FSA covers daycare expenses you

pay so that you (and your spouse) can work.

It’s simple. It’s smart. And it can give you a raise

by reducing your taxes. Sign up today and start pu� ng more money in

your pocket!

00148-02-0611 © 2011 e� exgroup, Inc.

��

How to Get Speedy Reimbursements

�� !��

"""�� #�!$%�&��'�(

)��*��"�%�� *��+(��*��"�,��# ��%- '��*.�� %*��-�%*��''�� &�� +�&%� #�!�%��*�!,�� *��#��

/�%��%�� "*� �$�+�&'��*�$�*+�&%(��+,�'�0& '�#+�� #+�

Complete, sign, and date an efl ex claim form�� +�& �%$�**�� $��*�*�� %(�"�'��.*�%�'��+�&%%�0&��*,�'�&�� *"��.*(��*�1�%�$&#�* ��2�&(�+ ��'#� ( �%(�*"""�� #�!$%�&��'�(3 �%(��4��&%�*� �'#&��(�#�+��%* ' ��*.� � �%(�* ��5 %�*��#��*��(�" *�*��#��* �&%� $ *�� 3��%��' �#��'&% *+6&(,�%7��+�&%'#� ( �%(��##%�#�*��'&(��*�* ��

Complete a Direct Deposit form�8 %�'*�� **�+�&%'��'� �$�%��- �$��''�&�*" ##��*��%� (,&%��(��*�%�'��-�+�&�*% �*�*��,��2�&��#+��*�'�(�#�*�*��8 %�'*8�� * �%(��'�&�#��+�&'��$�,��%�''�&�* � �%(�* ��

Attach receipts to document the expenses on your claim form:� Send an itemized bill or an Explanation of Benefi ts

(EOB) from your insurance carrier. ��'��.*�%�'��+�&%'#� ( %�(�'%�� *'�%��# �,�'�&�� *��.*��"�##� *��%�0& %�� %(�* ��9*�( � (&(�"��*��*�� %- '��'% �* �� *��%- '��*��%- '��%�- ��%��*��(�&�*'��%$��

� Don’t send a statement showing “Balance Forward.” :��1��+�"��'&(��*�* ��" �$*��*+��*&%�� %- '��*��*�� *��%- '��*��(�&�*� *��'��%$��9,�#��'�� %"�%��*�*�(��*&�&�##+��"��#+*��##�%�(�&�*�� *��.*(��*�1�%�0& %�(��*��

Submit claims for services you receive in the current plan year, not the previous year. 2�&%�#��+��%��*��*�� *��%- '�5��*, ## �$��*�7(&�*'� �' ��)�%�!�(�#�� +�&%�#��%&��*��'�#��%+��%5 ��;��&�%+*�%�&$�8�'�(,�%7��%- '��(&�*�''&%,�*"��;��&�%+��8�'�(,�%��5� +�&%�#�� '#&��*��(��*��!*�� +�&.##��-�&�* #��%'��79''�%� �$*�*��1��# $ ,#��!��%�,��*��*�� %- '�%�$�%�#�� "��+�&%�'� -��%��+*��, ##�

Use one of four methods to get your reimbursement: �7<�(�#�*��&%��# ��'#� ( �%(��'��+�&%��'&(��*�* ��=�7)9>+�&%'#� ( �%(" *��'&(��*�* ��=�7?(� #+�&%'#� ( �%(" *��'��'&(��*�* ��=�%78�"�#��% �*�&*�&%'#� ( �%(�*� #�!$%�&��'�(��(� # �*�� %(" *��'&(��*�* ��56�*��*� �(�*��" ##*��*��#��$��*7�8��.* �%$�**��##� +�&% *�(�*�$�*��%"�� ,#�� "�%�'� -�*��'#� ( �%(��'&(��*�* ��%�*�#+�*��%�.��$&�%��*��*��*"�.##$�**��( ��0&��* �#�%��%�%,��,#�*�0& '�#+(�*'�*��(&��4�'�&��"�� *��%�'� -�*��&�� '#� (� ��+�+�&'��#��!�� *�*��%�'�� $� +�&%'#� (,+%�(�(,�% �$*� �� (�#��*��

@&��* ��,�&* # �$�'#� (�%��+��'*� +�&%� #�!�#��A� <�##&��*�� ?(� #*�<&�*�(�%<�%�B� #�!$%�&��'�(� <��*" *�*��)#�!��%*�*� #�!$%�&��'�(

How does it work? Two Words: Tax Savings. If you want to get more spendable dollars out of your paycheck�you’ll love the efl exFSA. Contributing funds to your efl exFSA to cover eligible health expenses and premiums can actually decrease your taxable income!

This benefi t lets you take advantage of current tax laws by allowing you to set aside money for health and dependent care expenses as well as pay for your health insurance premiums with pre-tax dollars.

What does that mean? Take a look at how the efl exFSA gave this employee a monthly raise. In this example, the employee actually took home $189 more each month ($2,268 annually) by enrolling in the efl exFSA.

Important: Services must be incurred during your plan year. If you incurred an expense prior to your plan start date, but paid for it after the plan start date, it isn’t reimbursable. If you don’t use all of the money in your FSA by the end of the plan year, it’s forfeited. You don’t get it back and you can’t roll it over into the next year. So, be sure to plan carefully. Don’t worry. Most people have no trouble using up their funds and enjoying the great tax savings.

Simple Truth

Every Employee Should Take Advantage of a Flexible Spending Account (FSA)

Why is it so great? It’s simple: You take home more money!

2740 Ski Lane • Madison, WI 53713

Questions? Call us toll free at 1.877.933.3539 or visit us online at www.efl exgroup.com

00014-02-0810

No FSA Plan FSA Plan

Gross Monthly Income $3,500 $3,500

Pretax Medical Expenses $0 $100

Pretax Daycare Expenses $0 $400

Insurance Premiums $0 $175

Taxable Income $3,500 $2,825

Withholdings (28% for taxes, FICA $980 $791and Medicare)

Post-tax Medical Expenses $100 $0

Post-tax Daycare Expenses $400 $0

Post-tax Insurance Premiums $175 $0

Net Income (spendable) $1,845 $2,034

Interested? Here’s how it works.1. Your plan will begin on ________________________ and end on _______________________________2. Simply estimate what you would spend on medical expenses, daycare services, and/or individual insurance

premiums. Only put into the efl exFSA what you’ll realistically spend. (Use our handy Personal Planning Worksheet, available on our website, to help with your estimations.)

3. Complete and submit your enrollment form. 4. Starting with the fi rst pay period of your plan year, we’ll automatically deduct the amount you elected per pay

period from your gross wages (before taxes) and put into your efl exFSA. Your total election amount will be available for purchases on the fi rst day of your plan.

5. When you incur eligible medical expenses, daycare services, or individual insurance premiums, simply submit a claim form with your documentation showing the service, description and charges. If you have the efl ex Card, you can simply pay for the service with the efl ex Card instead of a check or cash. It works just like a debit card—from day one you can spend up to your annual election amount. (Daycare and individual insurance dollars can only be reimbursed according to the current available balance in your account.)

Put More Money in Your Wallet. Enroll today.

Claim Form Instructions

©2011 eflexgroup, Inc. · 2740 Ski Lane · Madison, WI 53713 · P: 877.933.3539 F: 877.231.1287 · E: [email protected]

Get your money fast in three easy steps: 1) Fill out the claim form completely and check to make sure your supporting documentation is complete and accurate. It should include: o Description of Service o Date of Service o Amount owed (after insurance has paid its portion) 2) Sign and date your form. 3) Fax your claim with supporting documents to 877.231.1287 or mail to our address below.

Claim and Documentation Examples

Helpful Hints to get your claim paid even FASTER! • The fastest way to get reimbursed is to file your claim online. It's simple and takes less than 5 minutes to file and upload your receipt. Go to eflexgroup.com and click File A Claim, then File Online to get started. • If you'd like to be reimbursed for on-going Dependent Care, Orthodontia or Individual Premium expenses, fill out this claim form and select the Recurring Payment box. With proper documentation, you only file once but continue to be reimbursed throughout the year. • Did you pay for your expense with your eflex Card? Don't forget to select Paid with eflex Card on the claim form. • Enroll in Direct Deposit. It's the fastest, greenest and most reliable way to get your money back (Form available online).

Employee ID: (first initial, last name, last 4 digits of Social Security #)Employee Name:

Email Address and/or Phone Number:Employer Name:

Section 2: Please list each eligible expense below.

Section 1: Complete employee account information.

Reimbursement Claim FormPlease complete this form to request reimbursement of expenses incurred by you and/or eligible dependents. Itemized documentation of each expense must be provided. For questions, contact Customer Care at 877.933.3539 or email [email protected].

I certify that the expenses for reimbursement requested from my accounts were incurred by me (and/or my spouse and/or eligible dependents), were not reimbursed by any other plan, and to the best of my knowledge and belief, are eligible for reimbursement under my reimbursement plans. I or (we) will not use the expense reimbursed through this account as deductions or credits when filing my (our) individual income tax return. Any person, who knowingly and with intent to injure, defraud or deceive any insurance company, administrator, or plan service provider, files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law. Where indicated, parking amounts claimed are without an available receipt and this certification includes such expenses.

Section 3: Please sign, date and fax the completed form to 877.231.1287 or email to [email protected].

Date:

©2011 eflexgroup, Inc. · 2740 Ski Lane · Madison, WI 53713 · P: 877.933.3539 F: 1.877.231.1287 · E: [email protected]

Recurring Payment

Paid with eflex Card Benefit Type

Date(s) of Service (From - To)

Format: MM/DD/YYDescription of Service Provider/Merchant

Patient or Dependent Name &

Birth Date

Dollar Amount

Claim Total

Under the Benefit Type column, select one of the following benefit codes for each expense. We will then apply the expense to the appropriate account: FSA - Flexible Spending Account LPFSA - Limited Purpose FSA PARK - Parking DCA - Dependent Care Account HRA - Health Reimbursement Arrangement TRANSIT - Transportation IND - Individual Premium Account HRA/FSA - Apply to HRA first and FSA if applicable ADA - Adoption Assistance

Signature:

Reset FormPrint FormReset Form

For the best experience, open this PDF portfolio inAcrobat 9 or Adobe Reader 9, or later.

Get Adobe Reader Now!

Let’s Connect (you’ll be glad you did)

Join Us Today And Be In The Knowwww.twitter.com/efl exgroup | www.facebook.com/efl exgroup | www.youtube.com/efl exgroup1

Another fi rst from

You can fi nd us in the places you already spend time. Join us on any (or all) of these social networks.

• Health and wellness news and advice• Reminders about your plan• Tips to help you make the most of

your plan

• Giveaways and prizes• Expert money saving tips• Articles and exclusive content

• Quick videos that clear up confusion • Health care reform changes that

impact your account

You’ll get:

www.efl exgroup.com

(((yyooouuu’’llllllllll bbbbbeee ggglllllllaaaddddddd yyyyoooouuuuu ddddddddiiiiiiiidddddddd)))))))) You can fi nd us in the places you already spendd titimee. JoJoinin u uss onon a anyny ( (oror a allll)) ofof t thehesese s sococial networks.

00139-02-0511AnAnototheherr fifirsrstt frfromommm

0010010010010010013939393939-39 0202020202-02 051051051051051051111111

Take Us With You

Another perk from

Access your efl ex account information on-the-go 24/7/365 from your iPhone, iPad or Android

00139-02-0511

Download the free e� ex Bene� ts App today! Save yourself time,

and never lose a dime.

view all of your accounts in one place • up-to-date account balancessee your plan end date and grace period • view claims history • check claims status

• see payment status • check for claims denials • totally secure access

To download, simply visit the

Apple App Store or Android Marketplace

and search “e� ex Bene� ts”

AnAnototheherr pepep rkrk f frorommmm00100100100100139393939-39 02020202-02 05105105105105111111

fsa enrollment form · fsa enrollment form employee information (please print clearly.) ... i also...

Documents