Get the free 2016/2017 FSA Enrollment Form - New Hope-Solebury School District

Your Available Flexible Spending Accounts Healthcare FSA Optional WAIVE If you elect this coverage then a pro rata portion of your annual election will be deducted from each remaining pay periods in the plan year 2016. Elect coverage - Write in the amount of your Plan Year Election The maximum election for 7/1/201 6 - 6/30/2017 is 2 500. New Hope - Solebury School District Enrollment Employee Profile Data Employee s Name Address Line 1 Form Plan Year 2016 7/1/2016 - 6/30/2017 BAS-Key...

How to fill out 20162017 fsa enrollment form

How to fill out 20162017 fsa enrollment form

1. Open the 20162017 fsa enrollment form
2. Read the instructions and requirements carefully
3. Fill out your personal information, including name, address, and contact details
4. Provide your Social Security number and employee ID, if applicable
5. Choose the type of coverage you want (e.g., medical, dental, vision)
6. Indicate the coverage start and end dates
7. Specify the amount you want to contribute to your FSA account
8. Review and double-check all the information you have provided
9. Sign and date the form
10. Submit the completed form to your employer or benefits administrator

Who needs 20162017 fsa enrollment form?

1. Employees who want to enroll in the 20162017 fsa program
2. Employees who desire to contribute pre-tax dollars for eligible healthcare expenses
3. Employees who are eligible as per their employer's policies

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What is fsa enrollment form?

FSA enrollment form is a form used to enroll in a Flexible Spending Account (FSA) benefits program.

Who is required to file fsa enrollment form?

Employees who wish to participate in the FSA program are required to file the enrollment form.

How to fill out fsa enrollment form?

To fill out the FSA enrollment form, employees need to provide their personal information, select the contribution amount, and choose eligible expenses to be reimbursed.

What is the purpose of fsa enrollment form?

The purpose of the FSA enrollment form is to enroll employees in a benefits program that allows them to set aside pre-tax money for eligible medical expenses.

What information must be reported on fsa enrollment form?

The FSA enrollment form requires information such as personal details, contribution amount, eligible expenses, and beneficiary information.