“We make benefits work for you.”

Take advantage of your company’s Flexible Benefit Plan and take home more money!

10805 Sunset Office Drive, Suite 401 • St. Louis, MO 63127 314-909-6979 • Toll free: 800-631-3539 • Fax: 314-909-6983 • www.beneflexhr.com

Give Yourself A Pay Raise!

Sometimes referred to as a cafe teria plan, flex plan, or a Section 125 plan — a Flexible Benefit Plan lets you set aside a certain amount of your paycheck into an account — before paying income taxes. During the year you have access to this account for reimbursement of expenses you regularly pay for, such as health care and dependent daycare.

When you use tax-free dollars to pay for these expenses, you realize an increase in your spending power and substantial tax savings.

A Flexible Benefit Plan helps your paycheck buy more!

1 2 3

Reimbursable expenses can include:• Deductibles, co-pays, and prescription drugs• Expenses not covered by insurance• Dental services & orthodontics• Eyeglasses, contacts, solutions & eye surgery• Weight-loss programs

(dual use, requires a doctor’s letter)• Chiropractic services• Psychiatric care & psychologist’s fees• Mileage for healthcare• Over-the-counter drugs that are medically

necessary with a doctor’s prescription• All non-drug, over-the-counter (OTC) items• Adult & child daycare services• For a complete list, visit www.beneflexhr.com

It’s as easy as…

Carefully read this material and choose which options make sense for you to participate in.

Determine how much you expect to spend during the year for each option.

Here’s how it works…Example: An employee makes $2,000 each month and decides to participate in their employer’s Flexible Benefit Plan. As a result, their insurance premiums and health and daycare expenses are paid with tax-free dollars, giving them an additional $100 each month!

Without the Plan With the Plan

Complete the attached participation form and return it to your Human Resources Department.

Employee’s Gross Earnings $ 2,000FICA, Federal, State Taxes ‑ $500Insurance Premium ‑ $100Health and Daycare Expenses ‑ $300

NET EARNINGS $ 1,100

Employee’s Gross Earnings $ 2,000Insurance Premium ‑ $100Health and Daycare Expenses ‑ $300Adjusted Gross Earnings $ 1,600FICA, Federal, State Taxes ‑ $400

NET EARNINGS $ 1,200

Monthly Expenses Monthly Expenses

What is a Flexible Spending Account (FSA)?A benefit provided by your employer that lets you set aside a certain amount of your paycheck into an account before paying income taxes. During the year you can be directly reimbursed from your account for qualified healthcare and daycare expenses.

Why should I participate in the FSA when I already have health insurance?This account is used to pay for expenses not covered by insurance.

If I set aside part of my pay, won’t I make less money?No. Your net take home pay will increase by the amount of taxes you did not pay. An example of how it may work for you is detailed in this brochure.

Can I change my contributions during the year?Only if you have a change in status such as: marriage; divorce; birth; adoption; or a change in employment status for you, your spouse, or your dependent.

What over-the-counter (OTC) items require a doctor’s prescription?Any over-the-counter item that is a drug requires a doctor’s prescrip-tion. For the most current list please visit www.beneflexhr.com.

What if I currently take the dependent care credit on my annual tax return?Whether or not to participate in the daycare portion of this plan depends on your income, filing status, number of dependents, and annual daycare expenses.

The amount you deposit into your Dependent Care Account reduces the amount, dollar for dollar, that you can claim as a credit on your tax return. Contact your tax advisor for further information.

How do I get reimbursed for my expenses?You may submit a claim online at www.beneflexhr.com through the employee portal or via our mobile app. Manual claims may be submitted with a claim form via fax, email, or mail.

Do I have to wait for the money to be depos-ited in my account in order to make a claim for reimbursement?

The annual amount you have allocated for the Medical Flexible Spending Account is available to you at any time throughout the plan year. The amount available to you from your Dependent Care Account is the amount you have contributed to date.

How do I know how much is available in my accounts?Each time you receive a manual reimbursement, you will receive a statement attached to your reimbursement check or advice of deposit that shows the dollar amount you have set aside as well as the amount you have been paid to date. Additional options include online, mobile app, and (IVR) phone line account information.

What happens to my accounts if I terminate my employment?You will be able to request reimbursement for healthcare and daycare expenses incurred through the date of termination. Check your Summary Plan Description for any additional rights or benefits provided by your company’s plan.

What if I don’t use all of the money I set aside in my accounts?Carefully review your estimated expenses before making the deci-sion to participate. Any contributions that are not used during the plan year may not be paid to you in cash.

What if I am not covered under my company’s health insurance plan?Good news! You and your family can still participate in the Medical or Dependent Care Flexible Spending Accounts.

How do I benefit by participating?Your biggest advantage is the tax savings. Every dollar you set aside in your account reduces your income taxes, and you can be reim-bursed for qualified expenses that you are already paying for!

Are there any negatives that I should know about?Yes, because you are not paying any social security tax on that por-tion of your income that has been redirected, your social security benefits may be slightly reduced.

FSA Common FAQsFSA Common FAQs

www.beneflexhr.com• Verify your election• View your account balance• Print claim forms• How and where to file claims• Look up qualified expenses

• Change in status rules• Eligibility requirements• Calculate your tax savings• Find participating IIAS merchants• How to contact us

Contact us with questions: (314) 909-6979 or (800) 631-3539

Online Enrollment1. Go to www.beneflexhr.com2. Click on EMPLOYEE3. Click on Employee Log-in4. Enter Username and Password5. Click on Enroll Now6. Read the plan description7. Click on Begin Your Enrollment Now8. Verify profile

9. Add/verify dependents (if applicable)10. Read plan rules and check box(es)11. Enter elections12. Choose reimbursement method13. Verify14. Click Submit15. Print confirmation

Step I: Your OptionsStep I: Your Options Step II: Determining Your Reimbursable ExpensesStep II: Determining Your Reimbursable ExpensesThere are several accounts you can participate in with the Flexible

Benefit Plan.I: Medical Flexible Spending AccountThis account reimburses you for healthcare expenses not covered by insurance. You set aside money, tax-free, through regular payroll deductions. During the year, you can be reimbursed directly from your account for those qualified healthcare services provided they are not covered by insurance.Common expenses that qualify for reimbursement are — doctor visits, deductibles, co-pays, prescriptions, mental health care, dental services, orthodontics, chiropractor services, eye exams, glasses, and contacts.II: Dependent Care AccountThis account reimburses daycare expenses for eligible children and adults. Through regular payroll deductions, you set aside part of your income to pay for these expenses on a tax-free basis. To qualify, your dependents must be:

• a child under the age of 13, or• a child, spouse, or other dependent who is physically or mentally

incapable of self-care and spends at least 8 hours a day in your household.

Qualified expenses for reimbursement include: adult and child daycare centers, preschool, and before/after school care.Please note: A dependent care credit is available on your annual tax return. Whether or not to participate in the daycare portion of this plan depends on your income, filing status, number of dependents, and annual daycare expenses. You will also receive your tax savings throughout the year, rather than once a year when you file your taxes. Contact your tax advisor for further information.III: Limited Flexible Spending Account— with an HSAThis account reimburses you “tax-free” for healthcare expenses not cov-ered by insurance similar to the Medical Flexible Spending Account. The difference is this account is compliant with HSA guidelines. It can only be used for dental, vision, and post-deductible expenses.IV: Additional BenefitYour employer may have included benefits in addition to the programs described above. Your Human Resources Department will send notifica-tion, along with this enrollment brochure, if any such additional benefits are being offered at this time.V: Premium Only PlanThis account allows you to pay for your employer-provided health and other insurance premiums with tax-free dollars. If you are covered under your employer’s health and/or other insurance plans, you are automati-cally enrolled in this account! Be sure to let your employer know if you don’t want your premiums paid tax-free.

By completing the following information, you can calculate your annual reim-bursable expenses. Take into consideration the ser vices to be provided during the upcoming plan year for you and your dependents.Healthcare ExpensesMedical (1)*Deductibles $ ___________Co-payments $ ___________Doctor visits $ ___________Prescriptions $ ___________Over-the-counter items $ ___________OTC medications with doctor’s prescription $ ___________Other $ ___________Total $ __________

Vision (2)Exams $ ___________Eye Surgery $ ___________Lenses/Frames $ ___________Contacts $ ___________Solutions $ ___________Other $ ___________Total $ __________Dental (3)*Routine Check-ups $ ___________Fillings/Crowns $ ___________Orthodontics $ ___________Other $ ___________Total $ __________Dependent Daycare ExpensesChildren $ ___________Adults $ ___________Total $ __________Other Reimbursable Expenses**Total $ __________Estimated Annual Expenses and Tax SavingsTotal Healthcare Expenses (add 1 + 2 + 3) $ ___________Total Dependent Daycare Expenses $ ___________Total Other Reimbursable Expenses $ ___________ Total Expenses $___________Tax Bracket Percentage (see below) ___________ %Annual Tax Savings $___________

(multiply total expenses by tax bracket percentage)

Savings Amount Per Paycheck $___________(divide total expenses by number of paychecks you receive each year - 52, 26, 24, 12)

Tax Estimate TableBased on a combination of social security, federal, and state income taxes.

If your annual Estimatedhousehold earnings are: tax rate is:Less than $30,000 25%$30,000 to $40,000 29%$40,000 to $70,000 31%Greater than $70,000 33%

These tax rates are estimates based on national averages and may not reflect your actual tax rate.* Cosmetic procedures like teeth whitening and face lifts are not eligible expenses for reimbursement.** An “Additional Benefit” may be offered by your employer. Check with your Human Resources Department.

BeneFlexHR Mobile Gives You...Anytime, anywhere convenience so you can make the most of your benefits.1. Download the BeneFlexHR Mobile App

(available on iTunes or Google Play)2. Use the same username and password you use to

access your account3. For more information or to view a demo, visit

www.beneflexhr.com/beneflexhr-mobile-application

Check Account Balance Online1. Go to www.beneflexhr.com2. Click on EMPLOYEE3. Click on Employee Log-in4. Enter your Username5. Enter Password6. Click Login

By Phone1. Dial toll-free 855-210-95272. Press 1 for English or

2 for Spanish3. Enter last 5 digits of

your SSN#4. Enter 5 digit zip code5. Follow prompts

Clip and Save

Participation Form for the Flexible Benefit PlanPlease complete all fields. Effective Date in the plan ____________________________________________ Date of hire ___________________________

Employer name ________________________________________________________________________________________________________________________

Employee name ___________________________________________ Social Security No. ________________________________ Date of Birth ________________

Department/Division _________________________________________________ E-mail ___________________________________________________________

Home address _________________________________________________________________________________________________________________________

Home phone ( _________ ) ___________________________________________ Work phone ( _________ ) ______________________________________________

First payroll effective date _________________________________________ Paycheck frequency_____________________________________________________

_____ Number of pay periods remaining in the plan year

Option I: Medical Flexible Spending Account Agreement❏ I elect to contribute $________ (before taxes) per pay period, which is $________ per plan year, to fund my account for reimbursement

of qualified out-of-pocket healthcare expenses not covered under my health and other insurance plans.❏ I decline to participate in this option for this plan year.

Option II: Dependent Care Account Agreement❏ I elect to contribute $__________ (before taxes) per pay period, which is $__________ per plan year, for funding reimbursement of qualified

dependent daycare expenses. (Maximum amount per calendar year is the lesser of: (1) $5,000 for married filing joint, or $2,500 for marriedfiling separate; (2) your spouse’s total annual compensation; or (3) ½ of your total annual compensation.(If you are single, the maximum amount is $5,000.)

❏ I decline to participate in this option for this plan year.

Option III: Limited Flexible Spending Account Agreement—with an HSA❏ I elect to contribute $__________ (before taxes) per pay period, which is $__________ per plan year, for funding reimbursement

of qualified Limited FSA expenses. A Limited FSA may cover dental, vision, and post-deductible expenses.❏ I decline to participate in this option for this plan year.

Option IV: Additional Benefit Do not complete this section unless you have received instructions from your HR department.❏ I elect to contribute $__________ (before/after taxes) per pay period, which is $__________ per plan year, for funding reimbursement

of this additional benefit outlined by my Human Resource department.❏ I decline to participate in this option for this plan year.

Option V: Premium Only Plan Agreement❏ I have enrolled in certain employer-sponsored insurance benefits. I understand that my share of the premium for these insurance

benefits will automatically be paid with pre-tax dollars. I also understand that if my required contributions for the elected benefits areincreased or decreased while this agreement remains in effect, my taxable income will automatically be adjusted to reflect that increaseor decrease.

❏ I decline to participate in this option for this plan year.

Option VI: Waiver of Tax Benefits❏ I have been given the opportunity to enroll in these tax-savings plans and have declined to participate. I understand that I will lose all tax

savings that I may have received as a participant.

street city state zip

My employer and I agree that my taxable income will be reduced each pay period by the amounts set forth in this agreement. I understand that I may change my election in the event of certain changes in my status. Prior to the first day of each plan year, I will be offered the opportunity to change my benefit election for the upcoming plan year. Any qualified expenses that are submitted by me will be reimbursed to me on a tax-free basis. Any contri butions that are not used during the plan year may not be paid to me in cash. I acknowledge that I have received, read, and understand the Summary Plan Description.

Employee Signature ___________________________________________Date ________________________________________________________

11

How does the Benny Card work? It works like a Mastercard®, with the value of your account contribution stored on it. When you have qualified eligible healthcare expenses at a business that accepts Mastercard®, simply use your Benny Card. The amount of your qualified purchases will be deducted automatically from your FSA (Flexible Spending Account) and the pre-tax dollars will be electronically transferred to the provider/merchant for immediate payment.

How does the Benny Card change how I am reimbursed for expenses?

Before the Benny Card, you were required to pay for your eligible expenses at the time of purchase, then submit claim forms along with all receipts. A check was issued, mailed to you, and then you cashed the check.With the Benny Card, you simply swipe the Card and the funds are automatically deducted from your employee benefit account for payment. The Benny Card eliminates most out-of-pocket cash outlays, paperwork, and the need to wait for reimbursement checks.

Is this just like other Mastercard® Cards? The Benny Card is a Mastercard® Card used only for qualified expenses. There are no monthly bills and no finance charges.

Do I need a new Benny Card each year? No, each year your Benny Card will be loaded with your new annual election amount at the start of each plan year. The card is good for five years.

What if I lose my Benny Card or need another one? You’ll receive two Benny Cards. You can request an additional or a replacement Card through BeneFLEX. Replacement Cards may also be ordered through the employee portal. The additional/replacement Card is $10, which may be deducted directly from your pre-tax account.

Activating Your Card How do I activate the Benny Card?

Call toll-free, 1-866-898-9795.What dollar amount is on my Benny Card when I activate it?

The dollar value on your Card will be the amount you elected to contribute to your employee benefit account during your annual benefits enrollment. It’s from that total dollar amount that eligible expenses will be deducted as you use your Card or submit manual claims.

Using the CardWhere can I use my Benny Card?

Doctor, Dentist, Chiropractor, Hospital, Pharmacy, and more. You can find additional information on where your card can be used by going to our website at www.beneflexhr.com and looking under EMPLOYEES, IIAS Info.

Are there places the Benny Card won’t be accepted? Yes. Examples include department stores, hardware stores, restaurants, bookstores, gas stations, and home improvement stores. The card will not work at discount stores, grocery stores, and pharmacies that have not implemented the IIAS system.

If asked, should I select “Debit” or “Credit”?The Benny Card is a stored-value card. You may choose “credit” and sign the receipt, or you may choose “debit” if you have set up the 4-digit PIN#.

Can I use the Benny Card if I receive a statement with a Patient Due Balance for a medical service?

Yes. If the expense occurred during the current plan year. Be sure you have money in your account for the balance due, simply write the Benny Card number on your statement and send it back to the provider.

How do I know how much is in my account?You can access your account information at www.beneflexhr.com, through our mobile app, or call the Interactive Voice Response System (IVR) at 855-210-9527.

Whom do I call if I have questions about my Benny Card?Call BeneFLEX at the phone number on the back of the Benny Card.

What if I have an expense that is more than I have left in my account?

By checking your account balance often—either online, on the mobile app, or by calling the IVR at 855-210-9527—you will have a good idea of how much is available. When incurring an expense that is greater than what is remaining in your account, you can split the cost at the register.

How does the IIAS system work?OTC products eligible for reimbursement by FSA programs are coded in the system and identified on the cash register receipt with a special FSA icon. The system automatically recognizes and separates eligible and ineligible OTC products. Cardholders can then pay for eligible OTC products using the Benny Card automatically debiting their FSA account. As a result, the claim is fully adjudicated and the transaction substantiated with no paper receipts or further verification required. For items not qualifying for FSA reimbursement, the participant must provide an alternative payment method. You still have to save all your receipts, as this is an IRS governed plan.

Will I have to submit copies of my receipts for purchases of over-the-counter (OTC) items?

No, not for non-drug OTC items. On July 1, 2009, the IRS required all grocery stores, discount stores, and pharmacies to have an Inventory Information Approval System (IIAS) in place. The IIAS system automatically recognizes and separates eligible and ineligible purchases. These purchases will not require you to submit a receipt. The card will only work at merchants that have the IIAS system. Visit our website www.beneflexhr.com and click on the IIAS Info under EMPLOYEES to access a list of merchants that have implemented the system. SPECIAL NOTE: For OTC drugs that are medically necessary, you will need to include your doctor’s prescription with your claim submission. Please refer to our Guidelines for Claims Submission on the back of the claim form. You still have to save all your receipts, as this is an IRS governed plan.

What about other purchases made with my Benny Card? Will I have to submit copies of my receipts for those purchases?

Always keep your receipts. Our system will recognize your pharmacy prescription purchases, doctor co-pays, and drug discount levels. Another great feature is our card can learn when you buy the same thing. For example, you go to the dentist, make monthly payments for braces, after the first payment is adjudicated, the card recognizes ongoing payments for the same amount at the same dentist.

New ParticipantsWatch for your new Benny Cards in the Mail

The Benny Card Benny ®

Your Card for Better Benefits

12/2012/20

5103GOODTHRU

PLEASE OPEN IMMEDIATELY

YOUR NEW EMPLOYEE BENEFITS MATERIALS ARE ENCLOSED

Do Not Throw Away

01062017

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FSA Eligible Expense List

Per IRS regulations, the following, while not intended to be complete, illustrates examples of section 213 eligible medical or medical-related expenses. Expenses must be incurred during the Plan Year from which you are requesting reimbursement. Expenses are considered incurred when service is rendered, not when service is billed or payment is made. Expenses cannot be reimbursed in advance of the date service is rendered.

• Acupuncture

• Ambulance fees

• Braille — books and magazines

• Breast Pump

• Childbirth classes — mother-to-beexpenses only; partner’s expensesnot eligible

• Chiropractic care

• Coinsurance

• Contact lens(es), solutions, andcleaners

• Crutches

• Deductibles

• Dental fees

• Dentures

• Denture adhesives

• Diagnostic testing fees

• Prescription eyeglasses

• Guide dog

• Hearing aids and batteries

• Hospital bills

• Insulin and diabetic supplies

• Laboratory fees

• Laetrile by prescription

• Nurse fees

• Obstetrical expenses

• Operations

• Orthodontia

• Orthopedic shoes

• Osteopath fees

• Oxygen

• Physician fees

• Practical nurse fees

• Prescribed drugs — seecosmetic exceptions below

• Psychiatric care

• Psychologist fees or individual therapy

• Radial keratotomy/Laser eye surgery

• Routine physicals

• Special communication equipmentfor the deaf

• Smoking cessation prescriptions

• Surgical fees

• Therapeutic care for drug and alcoholaddiction

• Prescribed therapy treatments

• Transplants

• Transportation expenses/mileageto receive medical care or services

• Tuition at special school for learningdisabled

• Wheelchairs

• X-rays

OVER-THE-COUNTER ITEMS Watch for updates at www.beneflexhr.com

*Eligible Items Subject to Change

Eligible without a Doctor’s Prescription Examples of Over-the-Counter Items that

require a Doctor’s Prescription

• Asthma flow meters • Gauze and gauze pads

• Band-aids • Heart rate monitors

• Blood pressure monitors • Heating pads

• Cholesterol tests • Incontinence supplies for adults

• Contact lens solution • Medical bracelets & necklaces

• Crutches • Medical tape

• Denture care products • Nebulizers

• Diabetes care: Blood test strips, • Orthopedic shoe inserts

glucose kits, monitors, • Sunscreen (15+ SPF)

and testers • Supports and braces

• Reading glasses • Thermometers

• First aid kits

• Acid controllers • Feminine anti-fungal/anti-itch

• Allergy & Sinus • Hemorrhoidal preps

• Antibiotic products • Hydrogen peroxide

• Anti-diarrheals • Laxatives

• Anti-gas • Nasal strips

• Anti-itch & Insect bite • Ointments

• Anti-parasitic treatments • Pain relief

• Baby rash ointments/creams • Respiratory treatments

• Callous and corn removers • Rubbing alcohol

• Cold sore remedies • Sleep aids

• Cough, cold & flu • Sunburn cream

• Digestive aids • Stomach remedies

• Eye drops • Wart removal products

EXAMPLES OF EXPENSES THAT MAY NOT BE CLAIMED AS PART OF THE PLAN: • Cosmetic surgery or treatment not done for the primary purpose of proper

functioning of the body or to prevent or treat illness or disease; including but not limited to face lifts, whitening or capping of teeth, hair transplants, or treatments including Retin-A and vein surgery. [To be eligible, treatments must be proven medically necessary.]

• Diaper service for infants • Ear piercing by a physician • Employment-related expenses (physicals, transportation) • Fitness programs or physical therapy for general health benefits • Illegal treatments • Insurance premiums, including contact lens insurance programs • Hygiene items • Expenses reimbursed by an HSA or HRA.

Dual use – requires doctor letter • Accommodations made for disabling

medical conditions • Foot spa • Gloves and masks • Herbs • Humidifier • Massagers • Minerals • Multivitamins • Special supplements • Vitamins • Weight Loss Programs

Note: Plan restrictions may apply. Check with your plan administrator.

BeneFLEX HR Resources, Inc. 10805 Sunset Office Drive, Suite 401, St. Louis, MO 63127 │ Email: info@beneflexhr.com │Website: www.beneflexhr.com

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FSA Claim Form

EMPLOYEE INFORMATION

Please check box if address is new

Dependent Care Reimbursement

Name of Dependent

Service period Name, Address, Taxpayer identifier number of provider of service Charge of Service From To

Total Dependent Care Amount Requested: $

Flexible Medical Benefits Patient’s Name Type of Services

Please Check One Box Below for Each Expense Type MD=Medical, Rx=Prescription, DN=Dental, VS=Vision

OTCS=Over-the-Counter Supplies

OTCD=Over-the-Counter Drug (Must include Rx along with receipt)

Date(s) of Service mm/dd/yyyy

Healthcare Mileage $0.17 per

mile*

Amount of Charge

MD RX DN VS OTCS OTCD From: To:

MD RX DN VS OTCS OTCD From: To:

MD RX DN VS OTCS OTCD From: To:

MD RX DN VS OTCS OTCD From: To:

MD RX DN VS OTCS OTCD From: To:

MD RX DN VS OTCS OTCD From: To:

MD RX DN VS OTCS OTCD From: To:

MD RX DN VS OTCS OTCD From: To:

NOTE: EVERY OTC DRUG CLAIM REQUIRES A COPY OF THE PRESCRIPTION TO BE ATTACHED.

Total Medical Amount Requested:

Please arrange documentation in order listed above. The undersigned participant in the Plan certifies that all expenses for which reimbursement or payment is claimed were incurred during the current period under the

company’s Cafeteria Plan. The undersigned participant in the Plan understands that expenses are “incurred” when a service is performed or care is provided, not when

the bill is paid. The undersigned certifies that all expenses for which reimbursement or payment is claimed on this form were incurred on the dates of service stated

above. The undersigned fully understands that he or she is alone fully responsible for the sufficiency, accuracy, and veracity of all the information relating to this claim and

unless an expense for which payment or reimbursement is claimed is a proper expense under the Plan, the undersigned may be liable for payment of all related taxes

including Federal, State, or City income tax on amounts paid from the Plan which relate to such expense.

_____________________________ Employee’s Signature (must be signed for proper processing) Date

To Submit a Claim: Visit us at www.beneflexhr.com and submit your claim electronically through the Employee Portal, (click on Employee, Employee Login) Submit your medical or dependent care claim on our mobile app, BeneFlexHR Mobile (available on iTunes or Google Play), or Send your claim form along with all supporting documentation directly to BeneFLEX via email: info@beneflexhr.com, fax: 314.909.6983

or mail: 10805 Sunset Office Drive, Ste. 401, St. Louis, MO 63127 (Please do not submit a claim for reimbursement if you used your Benny Card.)

Name: ________________________________________________ Last four digits of your Social Security #: ___ ___ ___ ___ Address: ______________________________________________ Company Name: _________________________________ City/State/Zip: _________________________________________

I provided the dependent care as stated above. _________________________________________ _______________ ___________ Provider’s Signature Date SSN/Tax ID

Claims Processing Deadline:

Tuesday at 3:00 p.m. CST; 1:00 p.m. PST. BeneFLEX issues checks on Thursday.*Mileage to and from provider to your home. If rate has changed, amount will be adjusted at processing.

09142015

PLEASE READ THIS BEFORE SUBMITTING YOUR CLAIM FORM GUIDELINES FOR CLAIMS SUBMISSION The Internal Revenue Code provides the following guidance:

Medical Reimbursement • The best receipt is an Explanation of Benefits from your insurance company.• If other receipts are submitted, they must show the following information:

1. Who rendered the service (name and address). 4. Amount of charge.

2. What type of service was rendered. 5. Any insurance payment, if applicable.3. Date service was provided, not a billing or due date.(Canceled checks and credit card slips are not allowable receipts.)

NOTE: In order to process your claim, all 5 pieces of information must be on each receipt.(This includes receipts for orthodontic services.)

• Any amount claimed which is a “Previous Balance” or “Balance Forward,” etc. cannot be paid unless the information statedin items 1-5 above is shown on the receipt.

• Receipts must show all expenses incurred. Any over-payment, pre-payment, etc., for which no services are listed, cannot bereimbursed.

• Over-the-Counter (OTC) drugs with doctor’s prescription and all other OTC items1. When and Who Sold the product (date, name, and address).2. Type of OTC purchased. Must show product or brand name.

3. Amount of charge.

Eligible Items Subject to Change See Current List at

www.beneflexhr.com

• Mileage Reimbursementeage incurred to and from your home or office to receive medical care is reimbursable through the FSA at the rate Mil

of $0.17 per mile. If rate has changed, amount will be adjusted at processing. Mileage claim must include substantiation. (i.e. provider invoice, receipt, etc.)

Dependent Care Reimbursement

All receipts must show the following information:

1. Who rendered the service (name and address).2. What type of service was rendered.3. Date of original service, not a billing date.4. Amount of charge.5. Federal ID number (facility) or social security number (individual).(Canceled checks and credit card slips are not allowable receipts.)

For Your Reference

• Scheduled processing date(s): Weekly or Daily (company specific)• To ensure you are reimbursed, all claims must be received by BeneFLEX HR Resources, Inc. no later than

3:00 p.m. CST and 1:00 p.m. PST Tuesday for weekly processing.• BeneFLEX phone numbers — (314) 909-6979 and (800) 631-3539 (outside St. Louis) or fax number (314) 909-6983.• If you terminate employment, any expenses incurred after your termination date are not eligible for reimbursement.

Medical Expenses can still be claimed if you continue your participation under COBRA.• If you fax your claim, keep a copy of the confirmation statement in case BeneFLEX does not receive your paperwork.• Please itemize the expenses on your claim form.• You can contact BeneFLEX HR Resources, Inc. by e-mail at info@beneflexhr.com or visit us online at www.beneflexhr.com

to review Frequently Asked Questions or download forms.

Check Your Account Balance • Visit us online at www.beneflexhr.com, click on “Employee” and then select “Employee Login.”• Download our mobile app, BeneFlexHR Mobile, (available on iTunes or Google Play).• Call our Interactive Voice Response System (IVR) at (855) 210-9527 and listen for the prompts.

BeneFLEX HR Resources, Inc. 10805 Sunset Office Drive, Suite 401, St. Louis, MO 63127 │ Email: info@beneflexhr.com │ Website: www.beneflexhr.com

NOTE: EVERY OTC DRUG CLAIM REQUIRES A COPY OF THE PRESCRIPTION TO BE ATTACHED.If the receipt does not show the name of the product, you can write the product name on the receipt. You must havethe cashier verify by signing their name. (Canceled checks and credit card slips are not allowable receipts.)

Mileage incurred to and from your home or office to receive medical care is reimbursable through the FSA at the rateof $0.235 per mile. If rate has changed, amount will be adjusted at processing. Mileage claim must include substantiation (i.e. provider invoice, receipt, etc.).

01062017

Direct Deposit Form

NO MORE WAITING FOR YOUR CHECK IN THE MAIL UPDATE THIS INFORMATION ONLINE IN THE EMPLOYEE PORTAL

Stop waiting for your check in the mail and start getting rewarded! Participants can elect to receive their reimbursement via direct deposit. Direct deposit reimbursements will be posted to your bank account within 1-2 business days following processing.

To file a claim, simply submit your claim online through the Employee Portal at www.beneflexhr.com or send your claim form directly to BeneFLEX via email, fax, or mail. Then, go online and login to the Employee Portal where you can review your claim status and verify your direct deposit information.

If you have any questions, please contact BeneFLEX HR Resources at: info@beneflexhr.com or call us at

(314) 909-6979 or toll free: (800) 631-3539 for calls outside the St. Louis area.

Employee Name: Last 4 digits of SSN:

Employer:

I hereby authorize BeneFLEX HR Resources to initiate credit entries to my (check one) checking

account or savings account listed below and the depository named below (Depository) to credit the same to such account as well as debit entries initiated in error.

Account Number:

Depository (Financial Institution): Branch:

City: State:

Bank ACH Routing Number:

The authority will remain in full force and effective until BeneFLEX HR Resources has received written notification from me of its termination in such time and in such manner as to afford BeneFLEX HR Resources a reasonable opportunity to act on it. I also understand by signing this, I am verifying I understand I am responsible for the accuracy of the initial information and the updating of these subsequent fields (i.e. Changing bank accounts, bank name changes, etc.).

Employee Signature: Date:

Tape or staple voided check here

** Direct deposit only processed with a copy of a voided check on file.

This can also be entered through the Employer and Employee portal. Authorization for Direct Deposit of Reimbursement Claims

Submit Form to: BeneFLEX HR Resources, Inc. Fax: (314) 909-6983│Email: info@beneflexhr.com│Website: www.beneflexhr.com

**An actual voided check or copy of a voided check must be attached**