F2010-001 (10/20) | FSA Plan Enrollment Form_No Carryover | Fax (863) 577-4460
Flexible Spending Account Enrollment Form
Flexible Benefits (125) Plan
Mail: MidAmerica Administrative & Retirement Solutions
Ph: (855) 329-0095
Employer Social Security Number
First Name Last Name M.I. Date of Birth (MM/DD/YYYY)
Mailing Address City State Zip
Email Address Telephone
Date of Hire
Choose carefully as your election is binding for the entire Plan Year. Any unused dollars remaining in your Flexible Spending Account at the
end of the Plan Year will be forfeited. Expenses/claims must be incurred during the Plan Year or Grace Period/Run-Out Period in order to be
eligible for reimbursement. See the Summary Plan Description for more details.
BENEFIT
PER PAY PERIOD # PAY PERIODS ANNUAL ELECTION
Health Care Reimbursement $_______________ $_______________ = $_______________
Dependent Care Reimbursement $_______________ $_______________ = $_______________
Please note: I understand the card is to be used exclusively for Qualified Expenses as defined by the plan in which I participate. If I use the card for an expense that is
not a Qualified Expense, I understand that I am indebted to my employer and must repay the full amount of the non-qualified expense. Payment on non-qualified
expenses may be in the form of an offsetting claim, personal check, electronic draft from my personal checking or savings account, a post-tax deduction from my
paycheck, or other options established by my employer.
I hereby elect to participate in the Flexible Benefits Plan and therefore authorize my Employer to reduce my wages on a pretax basis during each
payroll period in the following amount. I understand this election will be in effect for only the current Plan Year. I understand I must complete each
year.
I understand that I cannot revoke or change this election during the Plan Year unless there is a qualifying “Change in Status” event that affects my
or my dependents’ eligibility under this Plan or another employer plan. The rules regarding election changes are described in more detail in the
Summary Plan Description.
I understand that I must submit a claim and appropriate substantiating documentation (e.g. explanation of benefits, itemized bill) for out-of-pocket
medical, and/or Dependent Care expenses before I can be reimbursed. I certify that I will only submit claims for reimbursement under the Flexible
Spending Account Plan. I certify that I will not submit claims for reimbursement under the Flexible Benefit Plan for amounts that have already
been reimbursed by another source nor will I seek reimbursement for such amounts from any other source.
Participant Signature
Signature Date (MM/DD/YYYY)
Print Form
Clear Form
NOTE: Enter effective date of coverage: _______________
PARTICIPANT CERTIFICATION & SIGNATURE
MidAmerica Administrative & Retirement Solutions is the third-party administrator for your plan.
PLEASE RETURN THIS FORM TO YOUR EMPLOYER.
If you have questions regarding your plan enrollment, please contact MidAmerica at (855) 329-0095.
