BASIC NEO

Company Name*
Open Enrollment Contact Person*
First Last
Address*
Street Address City State ZIP Code
Phone Number*
Email*
Will you use our BASIC website for employees to enroll online (for annual open enrollment only)?**
*Please request online enrollment setup only if you are going to direct your employees to use the online site to enroll. A MINIMUM 3 DAY NOTICE REQUIRED.
- Yes (Not available for plans with fewer than 12 participants)
- No, we would like to use paper enrollment forms. (If you select this option, we will provide you with a spreadsheet to collect and submit your enrollment data to BASIC).
- No, we use a third party vendor for our open enrollment. We will send the data to BASIC once our enrollment is complete.
What is the name of the vendor you use?
How many employees are ELIGIBLE to participate in the FSA plan?
Please review your information before you click "Next."

We recommend that you end your FSA open enrollment and have all elections submitted no later than 14 business days before the start of the new FSA plan year. This will ensure that elections are processed before the start of the new FSA plan year.
Start of open enrollment*
Enter the date you will distribute forms or announce your FSA Open Enrollment.
MM slash DD slash YYYY
Your election deadline*
Enter the final date for employees to enroll online and/or return forms to you.
MM slash DD slash YYYY
How many payroll cycles does your company have? (i.e. weekly on Friday, bi-weekly on Thursday, semimonthly on the 15th and 30th, etc.)*
If you have more than 2 payroll cycles, please enter the first two cycles using this form. You may then upload any additional payroll calendars by using the upload option below.
- One
- Two
Payroll Cycle #1*
Use the cycle name and the day of the week or month that payroll checks are issued. For example: Weekly on Friday, Bi-weekly on Thurs, Semi- Monthly on 1st and 15th, etc.
Please provide the details of your first payroll cycle.*
Number of FSA deductions in plan year First Payroll deduction date Final payroll deduction date
Payroll Cycle #2 (Complete only if you have more than one pay cycle)*
Use the cycle name and the day of the week or month that payroll checks are issued. For example: Weekly on Friday, Bi-weekly on Thurs, Semi- Monthly on 1st and 15th, etc.
Please provide the details of your second payroll cycle*
Number of FSA deductions in plan year First Payroll deduction date Final payroll deduction date
Do you have a copy of your payroll calendar(s) to upload now?*
To ensure the most accurate payroll postings, we recommend submitting a copy of your payroll calendar for our records. If available, please upload a copy of your payroll calendar below. If you have more than 2 payroll cycles, please use the upload feature below to provide information on any additional payroll cycles not listed above.*
*Only one attachment can be uploaded. For multiple cycles, please include all calendars in one file/document.
Max. file size: 500 MB.
Please review your information before you click "Next."

Welcome to BASIC - CA and Akron, OH Locations

FSA Renewal Wizard

Step 1 of 3 - Company Information

Please review your information before you click "Next."

We recommend that you end your FSA open enrollment and have all elections submitted no later than 14 business days before the start of the new FSA plan year. This will ensure that elections are processed before the start of the new FSA plan year.

Please review your information before you click "Next."

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Please review your information before you click "Submit."

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