Bmsllc.net

P.O. Box 43653 Louisville, KY 40253-0653 (502) 244-1161 (800) 919-BMSI FAX (502) 244-1162 www.bmsllc.net
ELECTION FORM FOR THE FLEXIBLE BENEFIT PLAN Employer_______________________________________ Employee Name ____________________________________ Social Security # _________________________________ Date of Birth ___________________________________ Mailing Address _______________________________________City ____________________State_________Zip_________ Home Phone (_____)_________________________________E-mail Address______________________________________ (Highly Recommended for Debit Card Receipt Notification)
Spouse’s or Qualified Dependent’s Full Name (for an extra FSA Debit Card) _______________________________________ (Must be qualified dependent under IRS rules and regulations. If you wish to order extra cards, contact BMS after the start of the Plan Year.)
Debit Card Information for Participants: I understand that an FSA Debit Card will be ordered for me and/or my dependents based on the election(s)
indicated below. NOTE: I agree to use the Debit Card for only qualified medical and/or qualified daycare expenses. I understand that qualified
expenses paid with the card cannot be reimbursed by any other plan and that I will not seek reimbursement for expenses paid with the card from any
other source. I also understand that if a payment is made that is not for qualified expenses under IRS guidelines, I will repay the Plan. I also
understand that I am responsible for submitting all requested receipts to BMS to validate my card usage as required under IRS guidelines. Usage of
the Debit Card at a qualified merchant does not negate the need to submit receipts per current IRS rules and regulations if requested and necessary.
I agree to review my account online periodically at www.bmsllc.net to obtain information on open transactions that are in need of substantiation. I
realize that if I fail to respond to request for receipts within 60 days of the posting of the transaction, my Debit Card will be suspended. Full
compliance and submission of required receipts will be necessary in order to reactivate my Card. Notification of open transactions will be emailed to
the email address provided above or saved at my employee website at www.bmsllc.net. Also, the debit card agreement that is sent to me with my
card outlines the individual participant’s responsibility for proper use. A valid e-mail address is a highly recommended for card use in order to be
notified of items in need of receipts.
OPTION 1 HEALTH CARE FLEXIBLE SPENDING ACCOUNT (Health FSA)
YES I elect to contribute $___________ (before taxes) for the PLAN YEAR, which is $__________ per pay period (please calculate
based on the number of pays in your Plan Year) to fund my account that pays qualified out-of-pocket healthcare expenses not covered by my health and other insurance plans. The Plan Year Maximum is set by the employer – please confirm with them prior to completion. NO I decline this option for this Plan Year and understand that I will lose all tax savings that I could receive as a participant.
OPTION 2 DEPENDENT CARE ASSISTANCE PLAN (Dependent Care FSA)
YES I elect to contribute $___________ (before taxes) for the PLAN YEAR, which is $__________ per pay period (please calculate
based on the number of pays in your Plan Year) to fund my account that pays qualified dependent care expenses. Maximum amount per calendar year is the lesser of: (1) $5,000 for married filing jointly or $2,500 if married filing separate, (2) your spouse’s total annual compensation or (3) half of your total annual compensation. If you are single, the maximum amount is $5,000. NO I decline this option for this Plan Year and understand that I will lose all tax savings that I could receive as a participant.
OPTION 3 AGREEMENTS TO SAVE TAXES ON INSURANCE PREMIUMS
YES On the appropriate benefit enrollment forms, I have enrolled in certain employer-sponsored insurance benefits (i. e. health, dental,
vision insurance and other qualified pre-tax benefits.) I understand that my share of the premium for these employee benefits will automatically be paid with pre-tax dollars. I also understand that if my required contributions for these insurance benefits are increased or decreased while this agreement is in effect, my taxable income will automatically be adjusted to reflect that change.
NO I decline this option for this plan year and understand that I will lose all tax savings that I could receive as participant.
My employer and I agree that my taxable income will be reduced during the year by an equal portion of the benefit elections (1-3) set forth above
and that qualified expenses will be paid on a tax-free basis, I understand that I may change my election only in the event of certain changes in my
status and that, prior to the first day of each Plan Year, I will be offered the opportunity to change my benefit election for the upcoming Plan Year. I
can review the Summary Plan Description available through my Employer. I have also read and understand the Important Information provided with
enrollment materials.

Employee Signature: ______________________________________________________________Date_______________________________

Effective Date of Participation (mm/dd/yy) _____/______/_____ and end _____/_____/_____ First payroll start date _____/____/_____ Pay Cycle ___________________ 10/09 version

Source: http://www.bmsllc.net/PDFs/1BMS%20ELECTION%20%20FORM%20WITH%20DEBIT%20CARD-MASTER.pdf