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Flexible Benefits - Enrollment Form- 2011 Plan Year
Are you already enrolled??  Find out BEFORE you fill out this form. CHECK HERE!
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Privacy Information
        =Required Field
Printable Form
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Enrollee Information
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DOB:
SSN (no "dashes"):
Home Phone:  () -
Hire Date:
Work/Daytime Phone  () - extension
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. . . . .
Spouse & Dependent Information
(use comments for additional Dependents)
First MI Last DOB
Spouse 
Spouse SSN (no "dashes"):
Dependent 
Dependent 
Dependent 
Dependent 
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*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).*
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*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.*
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*I authorize the following to discuss my account*:
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If Other Representative Authorized:
First Name MI Last Name SSN
Other Rep. 
Relationship: 
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Flexible Compensation Reductions
Group Insurance Reductions-Per Pay Period1 Individual Reductions-Per Pay Period Annual
Group Medical  $ Medical, Dental, Vision $ $
Group Dental  $ Disability / Other Health Ins. $ $
Group Life  $ Dependent Care $ $
Other $ $
1Group insurance reductions automatically renew unless you terminate or change coverage. Premium increases or decreases, upon occurrence, are automatically updated.
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Comment,
Additional Dependents
(Name, DOB)

(255 characters max.)
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Questions?? > > Don't hesitate to call us at
(585) 385-6010 or (800) 836-8100
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flexbene.com,benefits plan,benefits partner
New York
PO Box 587
Pittsford, NY 14534
 
(585) 385-6010
(800) 836-8100
Fax: (585) 248-2488
info@flexbene.com
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