Fsa Enrollment Form - Select Account
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1FLEXIBLE SPENDING ACCOUNT
ENROLLMENT FORM
Complete and return to your employer
Group Information
Group Name:_________________________________________ SelectAccount Group Number:___________________________________
Location Name (if applicable): ______________________________________________________________________________________
Employee Information
SSN#: _______________________________________________ Primary Phone: _______________________________________________
Last Name: ___________________________________________ First Name: ________________________________ Middle Initial: _____
Street Address:_____________________________________________________________________________________________________
City: _________________________________________________ State: _________ Zip Code: ____________________________________
Email Address: _______________________________________________________ Date of Birth: ______/_______/_____________
Account Information
Medical Flexible Spending Account:
Plan year maximum __________________________________
(determined by employer, not to exceed IRS maximum of $2600)
Effective Date: ___________________________________________ (To be provided by Group Contact)
□
I want to contribute a total of $___________during this plan year to my Medical Flexible Spending Account.
I understand this amount will be deducted from my pay throughout the plan year.
Are you or your spouse actively contributing to a Health Savings Account?
□
No
□
Yes: Your medical FSA must be limited to dental and vision expense reimbursement until your health plan
deductible has been met. Contact SelectAccount to remove the limit when your deductible is met.
Dependent Care Flexible Spending Account
IRS Maximum: $5000.00
($2500 if married but filing separate tax returns)
Effective Date: ___________________________________________(To be provided by Group Contact)
□
I want to contribute a total of $___________during this plan year to my Dependent Care Flexible Spending Account.
I understand this amount will be deducted from my pay throughout the plan year.
Signature
I have reviewed the above elections and understand my choices will remain in effect for the entire Plan Year, unless I experience a
change in status as defined by the IRS. It is also my understanding that any funds remaining in my accounts at the end of the Plan
Year may be forfeited.
Signature: __________________________________________________________________ Date:
______________________
Employees: Complete and return this form to your employer.
Employers: Save time by entering this information online at least 30 days prior to your plan start date. Sign into Online Group Service
Center at Questions? Call Group Leader Services at 1-888-460-4013.
Send via secured email only:
Fax to:
Mail to:
SelectAccount.Documents
651-662-7247
P.O. Box 64193
866-231-0214
St. Paul, MN 55164-0193
X20049R03 (11/16)
MII Life, Inc. d.b.a. SelectAccount
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