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Flexible Benefits - Enrollment Form- 2008 Plan Year
Are you already enrolled??
Find out BEFORE you fill out this form.
CHECK HERE!
Privacy Information
=Required Field
Printable Form
Enrollee Information
DOB:
SSN (no "dashes"):
Gender?
Male
Female
Home Phone: (
)
-
Married??
Married
Single
Divorced
Employed by
AAC Contracting, Inc.
County of Suffolk
Crosby-Whipple Oil Corp.
D'Agostino General Contractors, Inc.
Daly, Sirianni & Co.
Energy Concepts
Genesis Pediatrics
Insero, Kasperski, Ciaccia & Co., P.C.
Nassau County
Nazareth Schools
Norman Howard Schools
Norry Management Corp
OCUSIGHT EYE CARE CENTER
Parkwest Women's Health
Qed Technologies, Inc.
R-J Taylor,General Contractors,Inc
Robinson & Gordon
Rochester Eye Associates
Rochester Otolaryngology Group, P.C.
Rotenberg & Co., Llp
Rural Opportunities, Inc. Seasonal
Rural Opportunities,Inc.
Sprague Insurance
Test
Tobin & Associates, Inc
Full Time?
Full Time
Part Time
Hire Date:
Work/Daytime Phone (
)
-
extension
Pay Periods/Year?
26
24
52
12
25
Spouse & Dependent Information
(use comments for additional Dependents)
First
MI
Last
DOB
Spouse
Spouse SSN (no "dashes"):
Dependent
Dependent
Dependent
Dependent
*
AUTHORIZATION
: I certify the above information to be correct and true to the best of my knowledge and that the dependents listed either reside with me in a parent-child relationship or are legally dependent on me for their support. I understand that any remaining dollars in my account(s) not used for eligible expenses incurred in the elected category during the Plan Year will be FORFEITED in accordance with current plan provisions and tax-laws. I understand that the Flexible Compensation reduction(s) will be in effect for the Plan Year and cannot be revoked unless I experience a change in family status or termination of my spouse's employment (See printed SPD).
*
Agree with Authorization?
Yes
*
I ALSO UNDERSTAND THAT the flexible compensation reductions may have some effect on my Social Security receipts.
To compensate for this I have been offered an optional supplement feature by my employer.
*
Understand the possible effect on Social Security receipts?
Yes
*
I authorize the following to discuss my account
*
:
Authorized to discuss account
Spouse
Other Representative
No Other Party Authorized
If Other Representative Authorized:
First Name
MI
Last Name
SSN
Other Rep.
Relationship:
Flexible Compensation Reductions
Group Insurance Reductions-Per Pay Period
1
Individual Reductions-Per Pay Period
Annual
Group Medical
$
Medical, Dental, Vision
$
$
Group Dental
$
Disability / Other Health Ins.
$
$
Group Life
$
Dependent Care
$
$
Other
$
$
1
Group insurance reductions automatically renew unless you terminate or change coverage. Premium increases or decreases, upon occurrence, are automatically updated.
Comment,
Additional Dependents
(Name, DOB)
(255 characters max.)
Questions??
> >
Don't hesitate to call us at
(585) 385-6010 x3007 or (800) 836-8100
New York
90 Office Park Way
Pittsford, NY 14534
(585) 385-6010 x3007
(800) 836-8100
Fax: (585) 248-2488
info@flexbene.com
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