BASIC NEO

TEST Open Enrollment Company

This is the NEO Test form. This form is for internal website testing and should not be used for client demonstrations. If you would like to use a company demo please use codes ABC or XYZ.

USING A DEBIT CARD WITH YOUR FSA: Your current Basic Prepaid Benefits card will be loaded with your 2019 election on January 1st so please do not discard it. Cards are valid for three years from date of issue. As a reminder, once your new plan year begins, only use the card for expenses incurred January 1st or after. Do not use the card for services rendered during the prior plan year. Learn more about Debit Card Guidelines.

VERSION 1

TEST Open Enrollment Company

TEST FORM - Version 2
SSN*
First name*
Middle initial
Last name*
Email
Address*
Street Address City State ZIP Code
Health Savings Account - Payroll Deduction*
Coverage Type*
Payroll Frequency*
HSA Per Pay Deduction - Single (Bi-Weekly)*
Please enter a number from 0 to 129.16.
HSA - Single (Annual Amount)
($3,100 Maximum)
HSA Per Pay Deduction - Family (Bi-Weekly)*
Please enter a number from 0 to 260.41.
HSA - Family (Annual Amount)
($6,250 Maximum)
Flexible Spending Accounts (FSA)*
Note: You can not enroll into the General Purpose FSA if enrolled into the HSA or Limited FSA.
General Purpose Health FSA Per Pay Period (Bi-Weekly)*
Please enter a number from 0 to 104.16.
General Purpose Health FSA (Annual Amount)
($2,500 Maximum)
Limited Health FSA (Vision & Dental) Per Pay Deduction*
Please enter a number from 0 to 104.16.
Limited Health FSA (Vision & Dental) Annual Amount
($2,500 Maximum)
Dependent Care FSA Per Pay Period (Bi-Weekly)*
Please enter a number from 0 to 208.33.
Elect the Dependent Care benefit only if you pay someone to care for a dependent child under age 13 or an older dependent who needs care while you work. Refer to the FSA brochure for additional information.
Dependent Care FSA (Annual Amount)
($5,000 Maximum)
Direct Deposit?
Bank Name
Routing Number

Enter your 9 digit routing number.
Account Type
Account Number
Terms and Conditions

I understand that:
Medical reimbursements will be available only for "qualifying health care expenses" for my qualifying dependents and myself as described in the Summary Plan Description.

Dependent care reimbursements will only be available for "qualifying dependent care expenses" as described in the Summary Plan Description. I agree to provide the claims administrator with the name, address, and taxpayer identification number of the dependent care service provider.

I agree to notify the Employer if I have reason to believe that any expense for which I have obtained reimbursement is not a qualifying expense. I also agree to indemnify and reimburse the Employer for any liability it may incur for failure to withhold federal, state, or social security tax from any reimbursement of a non-qualifying expense, up to the amount of additional tax actually owed by me.

I cannot change or revoke this election any time during the Plan Year unless it is on account of and consistent with a change in status as described in the Summary Plan Description and allowed under current Internal Revenue Code Section 125 regulations.

Any expenses paid through the plan may not be used as a credit or deduction on my federal tax return.

The amount of my compensation redirection shall be credited to a health care reimbursement and/or dependent care reimbursement account and I will be reimbursed for the applicable expenses incurred during the year.

My social security benefits may be slightly reduced as a result of my election.

Amounts that are not claimed for expenses incurred during the Plan Year coverage period will be forfeited and may not be paid to me in cash or carried over for expenses incurred after the Plan Year coverage period.

THIS AGREEMENT IS SUBJECT TO THE TERMS OF THE EMPLOYER'S HEALTH CARE REIMBURSEMENT PLAN AND/OR DEPENDENT CARE PLAN AS AMENDED FROM TIME TO TIME IN EFFECT, SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH APPLICABLE LAWS, SHALL TAKE EFFECT AS A SEALED INSTRUMENT UNDER APPLICABLE LAWS, AND REVOKES ANY PRIOR ELECTION AND COMPENSATION REDIRECTION AGREEMENT RELATING TO SUCH PLAN(S). I UNDERSTAND AND AGREE THAT BY COMPLETION OF THIS ELECTION BY CLICKING THE “SUBMIT” BUTTON, I HAVE AGREED TO THE ELECTIONS MADE UNDER THIS PLAN AND AM BOUND BY THE TERMS AND CONDITIONS OF THE PLAN.

Please read and confirm you agree with terms.
Please read the terms above.*
- I agree with the terms and conditions

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TEST Open Enrollment Company

TEST Open Enrollment Company

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