Home Insurance Flexible Spending Accounts Enrollment Application

Flexible Spending Accounts Enrollment Application

Flexible Spending Accounts Enrollment Application

 

INSTRUCTIONS: FLEXIBLE SPENDING ACCOUNT ENROLLMENT APPLICATION 
 
Alabama public employees who are active members of the state-administered PEEHIP health insurance plan can use the application discussed in this article to enroll in a flexible spending account. You may obtain this from the website maintained by the Retirement Systems of Alabama. You may also enroll online via this website.
 
Flexible Spending Account Enrollment Application Step 1: The first section concerns subscriber information. Enter your Social Security or PID number in the first box.
 
Flexible Spending Account Enrollment Application Step 2: Enter your first name in the second box.
 
Flexible Spending Account Enrollment Application Step 3: Enter your middle name or initial in the third box.
 
Flexible Spending Account Enrollment Application Step 4: Enter your last name in the fourth box.
 
Flexible Spending Account Enrollment Application Step 5: Enter your mailing address in the fifth box.
 
Flexible Spending Account Enrollment Application Step 6: Enter your city in the sixth box.
 
Flexible Spending Account Enrollment Application Step 7: Enter your state in the seventh box.
 
Flexible Spending Account Enrollment Application Step 8: Enter your zip code in the eighth box.
 
Flexible Spending Account Enrollment Application Step 9: Enter your date of birth in the ninth box.
 
Flexible Spending Account Enrollment Application Step 10: Enter your home phone number in the tenth box.
 
Flexible Spending Account Enrollment Application Step 11: Enter your work phone number in the eleventh box.
 
Flexible Spending Account Enrollment Application Step 12: Enter your email address in the twelfth box.
 
Flexible Spending Account Enrollment Application Step 13: The next section concerns enrolling in a healthcare flexible spending account. Indicate whether or not you wish to enroll with a checkmark. If yes, indicate whether you wish to apply for a Flex Debit Card, a Traditional Reimbursement, or a Manual Reimbursement. 
 
Flexible Spending Account Enrollment Application Step 14: Enter your monthly contribution amount. Multiply this by 12 to determine to your annual contribution amount.
 
Flexible Spending Account Enrollment Application Step 15: The next section is for those who wish to apply for a Dependent Care Flexible Spending Account. Indicate whether or not you wish to do so with a check mark. Enter your monthly contribution amount and multiply it by 12 to determine your annual contribution account.
 
Flexible Spending Account Enrollment Application Step 16: Sign and date the bottom of the form.
 

Download the PDF file .

Comments

comments