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ENROLLMENT INSTRUCTIONS
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| 1. |
Read the material about the Plan in Your Employer. |
| 2. |
Pay special attention to the Questions and Answers
form. |
| 3. |
Fill out the Confidential Survey Form. Remember to
estimate expenses you expect during the NEXT plan year, NOT last plan year! |
| 4. |
From the Survey Form, categorize your expenses.
| Category |
Expenses |
| I |
Employer sponsored Health, Dental, Long Term Disability and non-statutory Short-Term
insurance premium (if you do not have a payroll deduction for Survey Form items lA-C you
do not have expenses in this category.) |
| II & III |
All Child Care and other dependent care costs for care of an eligible dependent while
both spouses work. (This may include a dependent elder.) You will need the Social Security
number or the Tax Identification number of the person or entity which provides the
dependent care, even though we do not report that number to the IRS. When claiming a
dependent care deduction, you must file Form 2441 with your annual 1040. This category can
also be used for eligible adoption assistance expenses. Please contact your HR Director or
us to determine if your employer offers an Adoption Assistance
account (or check Your Employer). |
| IV& V |
All out of pocket medical, dental and vision care expenses. These are expenses not
covered or only partially covered by your insurance. Specific exclusions to these
types of expenses are cosmetic procedures, incidental supplies, vitamins, etc, which do not require a prescription. UPDATE - Over The Counter Medications From your Survey Form, items for
inclusion in this Category include IV, A-J; and V, A-G. |
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| 5. |
Take the total of your anticipated expenses in each category and divide each total by
the number of pay periods in the Plan Year. Transfer these amounts to the Flexible
Compensation Enrollment Form. Your Employer may have a
customized form. Go to Your Employer for instructions specific
your enrollment. |
| 6. |
Complete the top information of the Flexible
Compensation Enrollment Form (or this
PDF version). |
| 7. |
Contact the Flex Hotline toll-free at 1-800-836-8100
or (585) 385-6010 x3007 between 9:00am and 4:30pm (EST) to request help with
your enrollment or to verify the ability to deduct an expense. |
| 8. |
Fill out the on-line form or mail the completed Enrollment Form (PDF version) and Survey Form to us, or your HR Director by your
employer-specified deadline (see Your Employer). |
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