FLEXIBLE BENEFITS PLAN ELECTION FORM by fvp12618

VIEWS: 11 PAGES: 6

									        FLEXIBLE BENEFITS PLAN ELECTION FORM AND CASH COMPENSATION AGREEMENT

Employee Name:
                         Last                                       First                               Middle Initial

Employee Address:
                          Street                                    City                                State            ZIP

Employee Social Security Number:                                                       Date of Birth:

Employer Name: St. Joseph Public Schools

Plan Year: January 1, 2010                                   through December 31, 2010

Spouse Name:
                         Last                                       First                               Middle Initial

Spouse Social Security Number:                                                         Date of Birth:

Spouse’s Employer Name:

Does any dependent have health coverage elsewhere?            No      Yes Carrier:

NOTICE FOR EMPLOYEES WITH AN HSA OPTION: If you choose to enroll in the employer’s high-deductible health
plan/health savings account (HSA) option, you may elect to also participate in the medical flexible spending account (FSA).
However, you and your family will be eligible to be reimbursed under the medical FSA only for certain limited purposes such as
uninsured dental and vision expenses, preventive care, and other expenses incurred after the minimum annual deductible
under the employer’s high-deductible health plan is satisfied. The account will be known as a combination limited-
purpose/post-deductible medical FSA. These restrictions are necessary in order to make sure you continue to be eligible to
make contributions to the HSA or have the employer make contributions to the HSA on your behalf. If you elect the high-
deductible health plan/health savings account option and also elect to participate in the medical FSA, you should estimate your
expenses for the medical FSA in light of these limited-purpose restrictions.

   I choose to participate in the employer’s high-deductible health plan/HSA option.
   I choose not to participate in the employer’s high-deductible health plan/HSA option.

If your spouse or other dependent is enrolled in a high-deductible health plan and HSA through his or her employer or another
source, you should not elect to participate in the employer’s medical FSA for the plan year. If you elect to participate, it will
cause your spouse or other dependent to be ineligible for the HSA. An individual enrolled in an HSA cannot participate in a
non-high-deductible health plan, and the medical FSA is a non-high-deductible health plan for this purpose.

I have enrolled for certain benefit coverages on the appropriate benefit enrollment forms. In accordance with my rights under
the plan, I elect the following benefits and designate the following amounts for each benefit I have selected for the plan year
specified above. The employer and I agree that my cash compensation will be reduced by the amounts set forth below for
each pay period and plan year (or during such portion of the year as remains after the date of this agreement).

The maximum contribution that any participant may make under the medical reimbursement program in any
plan year is $ 3,000.00 . The minimum is $ 150.00                  .

The maximum contribution that any participant may make under the dependent care reimbursement
program in any plan year is $5,000 ($2,500 if the participant is married and files a separate tax return).

Coverage Type                                            Contribution per                     Total Annual Amount
                                                         Pay Period

          Health, Dental, & Other Premiums               $                                    $

          Medical Reimbursement Program                  $                                    $

          Dependent Care Reimbursement Program           $                                    $

First Payroll Deduction Date: 01/08/10 Amount of Employer Contribution: $0.00
FLEX.ENR.DC                                                    1
Revised 9/17/08
I understand the following:

     •   The reduction in my cash compensation under this agreement shall be in addition to any reductions under any other
         agreements or benefit programs maintained by my employer.
     •   The plan administrator may reduce or cancel my compensation reduction or otherwise modify this agreement in the
         event the plan administrator believes it advisable in order to satisfy certain provisions of the Internal Revenue Code.
     •   Before the beginning of each plan year I will be offered the opportunity to change my benefit election for that plan year.
         My Summary Plan Description contains details on annual benefit election procedures, including the procedure
         for making a new election at the beginning of the plan year.
     •   If my required premiums for the elected benefits are increased or decreased while this agreement remains in effect,
         my cash compensation reduction will automatically be adjusted to reflect that increase or decrease.
     •   I cannot change or revoke any of my elections or this compensation reduction agreement at any time during the plan
         year unless I have a change in status as defined by the plan, including marriage, divorce, death of a spouse or
         dependent, birth or adoption of a child, termination or commencement of my spouse’s employment, change in my
         spouse’s employment status from full-time to part-time or from part-time to full-time, an unpaid leave of absence by my
         spouse or myself, or such other events as permitted by federal law that the plan administrator determines will permit a
         change or revocation of an election.
     •   My social security benefits may be reduced because my compensation reductions decrease the amount of
         contributions that are made to the Federal Social Security system.
     •   If I receive reimbursement from my medical reimbursement account without adequate substantiation, or if I terminate
         participation (e.g., terminate employment) and I have received benefits from my medical reimbursement account for
         the plan year that exceed the amounts I have contributed for the plan year, my employer may take any permissible
         action to recover the excess.

METAVANTE BENEFITS CARDS

When you complete and return your election form, a Metavante Benefits Card will be sent to you. Use of the Benefits Card
indicates your agreement to, and acceptance of, the terms of the Metavante Flex Convenience user agreement. You may use
the Benefits Card to pay for eligible expenses, but only at specific locations, such as a pharmacy or a doctor’s office. If a
service provider will not accept the Benefits Card, you must file a benefit claim form as described in your Summary Plan
Description. You are responsible for all of the charges on the Benefits Card. If you use the Benefits Card for an expense not
deemed to be “eligible,” the plan administrator may require additional information about the expense and may ask you to repay
the amount debited.

     Employee requests a Metavante Benefits Card for the following dependents:

             Name                      Relationship to               Address (if Different)             Social Security No.
                                         Employee




This agreement is subject to the terms of the employer's flexible benefits plan, as amended from time to time; shall be
governed by and construed in accordance with the applicable laws; and revokes any prior election and compensation
reduction agreement relating to such plan.



I elect to participate in the above plan(s) in accordance with this agreement and the terms of the employer’s flexible
benefits plan. ALL FORMS MUST BE DATED BY NO LATER THAN 12/31/2009!

                                                                                                                 /        /
Employee's Signature                                                                                    Date

Accepted and Agreed to by:
                                  Administrator

                                                                                                                 /        /
By                                                                                                      Date
FLEX.ENR.DC                                                     2
Revised 9/17/08
I elect NOT to participate in the above plan(s) and to receive my full compensation in cash.

                                                                                                 /   /
Employee's Signature                                                                      Date

Accepted and Agreed to by:
                             Administrator

                                                                                                 /   /
By                                                                                        Date




FLEX.ENR.DC                                             3
Revised 9/17/08
                  EMPLOYEE BENEFITS PLAN – CHANGE IN STATUS

Employee Name:
                     Last                              First                          Middle Initial

Employee Address:
                        Street                         City                   State              ZIP

Employee Social Security Number:

Employer Name: St. Joseph Public Schools

Plan Year: January 1, 2010                                             through December 31, 2010

I previously signed an Election Form with the employer in connection with the
plan, and I am requesting a change in my election.

Complete Parts I and II.

I.      Change in Status

        I have had the following change in status (as defined by the plan) since I signed the Election
        Form (check one):

                       I have been married.

                       I have been divorced or legally separated or my marriage has been annulled.

                       My spouse has died.

                       I have had a child (birth, adoption, or placement for adoption).

                       My child has died.

                       My spouse or dependent has begun employment.

                       My spouse or dependent has terminated employment.

                       My employment status is affected by a strike or lockout.

                       The employment status of my spouse or dependent is affected by a strike or
                       lockout.

                       I have taken an unpaid leave of absence.

                       My spouse or dependent has taken an unpaid leave of absence.

                       I have changed my work site.

                       My spouse or dependent has had a change in work site.

                       I have had the following change in employment status that affects my
                       eligibility for benefits. Explain:




FLEX.ENR.DC.SC                                    1
Revised 5/27/08
                       My spouse or dependent has had the following change in employment status
                       that affects his or her eligibility for benefits. Explain:



                       My dependent now satisfies the requirements for coverage owing to the
                       attainment of a specified age, student status, or similar circumstance.

                       I have changed my place of residence.

                       My spouse or dependent has changed his or her place of residence.

                       I am going on an FMLA leave and elect to revoke my election with respect to
                       the employer’s group health insurance plan or the medical reimbursement
                       account.

                       I am returning from an FMLA leave and elect to reinstate my election with
                       respect to the employer’s group health insurance plan or the medical
                       reimbursement account.

                       My cost for dependent care service has increased or decreased and I elect
                       to make a corresponding change under my dependent care reimbursement
                       account. (Note: An election change is not permitted in this situation if your
                       dependent care provider is a relative.)

                       My spouse, former spouse, or dependent is enrolled in his or her employer’s
                       plan and that plan has a different 12-month election year than this plan. My
                       spouse, former spouse, or dependent has made an election during the open
                       enrollment period of his or her employer’s plan and I elect to make an
                       election change that is on account of, and corresponds with, the election
                       change under the other plan.

                       I have exercised special enrollment rights under HIPAA and elect to increase
                       my coverage under the employer’s group health insurance plan.

                       I have a court order resulting from divorce, legal separation, annulment, or
                       change in legal custody, including a qualified medical child support order
                       regarding health coverage for my child. If the order requires coverage under
                       the employer’s group health insurance plan, I elect coverage for my child. If
                       the order requires my former spouse to provide health coverage, I elect to
                       cancel the employer-provided health coverage for my child.

                       My spouse, my dependent, or I have been entitled to Medicare or Medicaid
                       (other than Medicaid coverage consisting solely of pediatric vaccine benefits)
                       and have lost eligibility for such coverage. I elect to begin or increase
                       employer-provided group health coverage for the affected individual(s).

        I understand that I may change my election ONLY IF it is on account of and corresponds
        with the change in status as indicated above.

II.     Participant Representations

        I understand that this change in my election will be effective after the plan administrator
        approves it, as provided below. I also understand that this election may not be changed
        during the remainder of the plan year unless I have another change in status.


FLEX.ENR.DC.SC                                   2
Revised 5/27/08
I certify that all the information in this document is true. I agree to supply any additional
information that the plan administrator, in its discretion, determines is necessary to process
my request for a change in my benefit election.


                                                                               /      /
Employee’s Signature                                                    Date


Accepted and Agreed to on behalf of:
                                       Administrator

                                                                               /      /
By                                                                      Date

Effective Date of Change:




FLEX.ENR.DC.SC                                  3
Revised 5/27/08

								
To top