MEMBERS

Flexible Spending Accounts (FSA)

A Flexible Savings Account saves you money by letting you set aside funds from your paycheck into an account before paying income taxes. Then, you can use money to pay for your regular health- and dependent-care expenses with pre-tax dollars. It's up to you to decide how much to contribute to your FSA account based on your needs, but each dollar set aside is an opportunity to save on taxes.

More information

APPLY ONLINE

Choose Medical Reimbursement, Dependent Care or both. Please fill in all fields. Incomplete applications will not be accepted.

Important: If you elect HDHP option (example…Humana’s HDHP option), use the Limited FSA application.

Employment Information

Employer Name:*

If other please specify:

Paycheck frequency is .

Is this for a short plan year (less than 12 months)?
Yes    No

If yes, enter number of pay periods:

First payroll deduction date will be (MM/DD/YYYY).

(FSA) Medical Reimbursement Account

How will your Medical Reimbursement Account be funded?

I will personally fund the account in the amount of $ (before tax) per pay period.

My employer will fund the account in the amount of $ (before tax) per pay period.

$  for this plan year

(HRA) Health Reimbursement Account

How will your Health Reimbursement Account be funded?

I will personally fund the account in the amount of $ (before tax) per pay period.

My employer will fund the account in the amount of $ (before tax) per pay period.

$  for this plan year

(DCA) Dependent Care Reimbursement Account

How will your Dependent Reimbursement Account be funded?

I will personally fund the account in the amount of $ (before tax) per pay period.

My employer will fund the account in the amount of $ (before tax) per pay period.

$ annually* (must not exceed $5000)

Your Personal Information
Title*
 First Name*
 Last Name*
Mailing Address*

 Daytime Phone Number*
City
 State & ZIP Code
 
Email Address*
Benifits Card Due to security precautions please call

1-800-489-1539 to request your Benefits card.

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