Pre-Tax Flexible Benefit Program
Enrollment Form- 2020 Plan Year

Privacy Information *=Required Field Printable Form

Employee Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Home Phone Number

Email Address *

Gender *

Marital Status *

Phone Number (Cell or Home) *

Date of Birth *

Are you a new 2020 participant? *

SSN *

Confirm Your SSN *

Hire Date

Are you employed by the County or College? *

College Employment Status *

Please submit a paper enrollment form. (Click Here)

Adjuncts are not eligible to submit online enrollments.

Spouse and Dependent Information

Spouse

First Name

Last Name

DOB

Spouse SSN (no "dashes"

Dependent

First Name

Last Name

DOB

Add another dependent

Dependent

First Name

Last Name

DOB

Add another dependent

Dependent

First Name

Last Name

DOB

Add another dependent

Dependent

First Name

Last Name

DOB

Authorizations

*AUTHORIZATION: I certify the above information to be correct and true to the best of my knowledge and that the dependents listed either reside with me in a parent-child relationship or are legally dependent on me for their support. I understand that any remaining dollars in my account(s) not used for eligible expenses incurred in the elected category during the Plan Year will be FORFEITED in accordance with current plan provisions and tax-laws. I understand that the Flexible Compensation reduction(s) will be in effect for the Plan Year and cannot be revoked unless I experience a change in family status or termination of my spouse's employment (See printed SPD)* *

Yes

*I ALSO UNDERSTAND THAT the flexible compensation reductions may have some effect on my Social Security receipts. To compensate for this I have been offered an optional supplement feature by my employer.* *

Yes

*I have read and understand the Summary Plan Description that governs this Plan *

Yes

*I authorize the following to discuss my account*: *

Other Representative

First Name

Last Name

SSN

Relationship

EMPLOYEE ELECTIONS

Please note: For those employees on the regular 26 pay period schedule the County takes deductions over 25 pay periods, no deduction will be taken the first pay period of 2020. If you are not on the 26-pay period schedule, please be sure to indicate your number of pay periods below.

Unreimbursed Medical, Dental, Vision Expenses

Maximum of $2,750 per Plan Year You MUST enroll in at least $1 per pay period in order to carryover up to $500 of 2019 remaining funds. DO NOT include carryover funds in this election

$ Per Plan Year (Health Expenses):

# of pay periods

$ Per Pay Period:

0.00

# of pay periods

$ Per Pay Period:

0.00

Dependent Day Care Expenses (For dependents ages 12 and younger; includes daycare, summer day camps & before/after care services) Maximum of $5,000 per Plan Year / $2,500 if married filing separately

A DEPENDENT CARE REGISTRATION STATEMENT IS REQUIRED TO BE SUBMITTED BEFORE REIMBURSEMENT.

$ Per Plan Year (Dependent Day Care):

# of pay periods

$ Per Pay Period:

0.00

# of pay periods

$ Per Pay Period:

0.00

Adoption Assistance Maximum of $14,300 per Child

$ Per Plan Year (Adoption):

# of pay periods

$ Per Pay Period:

0.00

# of pay periods

$ Per Pay Period:

0.00

AFLAC Disability Premium*

Maximum enrollment equals cost of coverage billed by the COUNTY.

You must already be enrolled in an AFLAC disability option billed by the COUNTY.

$ Per Plan Year (AFLAC):

# of pay periods

$ Per Pay Period:

0.00

# of pay periods

$ Per Pay Period:

0.00

COBRA (billed through Suffolk County)

Maximum enrollment equals cost of coverage

$ Per Plan Year(COBRA):

# of pay periods

$ Per Pay Period:

0.00

# of pay periods

$ Per Pay Period:

0.00

PBA/Probation Group Insurance Reductions

Please note that this is not a reimbursement account.

It is the election to have the PBA/Probation Major Medical Deduction

taken pre-tax. Must be a member of the PBA/Probation to enroll.

If you are already enrolled it will be automatically carried over

Choose One

By Clicking "Continue", You Are Finished And Will Submit Your Enrollment Form to Flexbene

Pre-Tax Flexible Benefit ProgramEnrollment Form- 2020 Plan Year

Employee Information

Spouse and Dependent Information

Authorizations

EMPLOYEE ELECTIONS

Pre-Tax Flexible Benefit Program
Enrollment Form- 2020 Plan Year