FLEXIBLE SPENDING ACCOUNT AND DEPENDENT CARE
NOTE: Due to IRS regulations, Human Resources now requires enrollment forms be submitted annually for Flex Spending Account and/or Dependent Care Accounts. Thank you in advance.
- Please DO NOT send any enrollment forms to individuals within Human Resources
The Enrollment form should be filled out and submitted to: email@example.com on or before 10/11/2019.
2019 Flexible Benefit Account Enrollment Form
***** ANY ENROLLMENT FORMS NOT RECEIVED BY END OF BUSINESS ON OCTOBER 11, 2019 WILL CONSTITUTE A WAIVE OF COVERAGE REGARDLESS OF YOUR SELECTION ON THE QUESTIONNAIRE****