Flexible Benefits (Cafeteria Plan)
You must participate in this plan if you elected dental coverage. For more information, click here, handbook pages 8-14.
To enroll
- Verify all information is correct and complete. If not, make changes and fill in missing information. Effective Date is your hire date. Monthly/Biweekly is how you will be paid.
Section I
- Indicate beside the specific benefit plan the monthly premium you want pre-taxed.
Section II
- Flexible Spending Account (FSA) Elections, if you wish to participate indicate the monthly (even though you may be paid biweekly) deduction amount for A. Medical Reimbursement Plan and/or B. Dependent Care Reimbursement Plan.
- Total Monthly FSA Elections - add the totals above.
- Total Annual Medical Reimbursement Plan - multiply the monthly amount by 12.
- Total Annual Dependent Care Reimbursement Plan - multiply the monthly amount by 12.
Participation and salary reduction agreement
- Print, sign and date in large box area.
To waive
- Verify all information is correct and complete. If not, make changes and fill in missing information.