Pre-Tax Flexible Benefit Program
Enrollment Form- 2021 Plan Year

OPEN ENROLLMENT PERIOD FOR THE 2021 PLAN YEAR
09/15/2020 - 12/15/2020
No Enrollments will be accepted after 12/15/2020, NO EXCEPTIONS
If you would like an enrollment package mailed to you,
please email info@flexbene.com with your name and mailing address.
 
                    Privacy Information                                     *=Required Field                                                             Printable Form      

Employee Information

Please submit a paper enrollment form. (Click Here)
Adjuncts are not eligible to submit online enrollments.

Spouse and Dependent Information

Spouse

Dependent
Dependent
Dependent
Dependent

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)* *
*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.* *
*I have read and understand the Summary Plan Description that governs this Plan  *
Other Representative

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 2021. 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. Up to $550.00 from 2020 Plan Year may carryover for use in the 2021 Plan Year. DO NOT include carryover funds in this election
$ Per Pay Period:
0.00
$ 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 Pay Period:
0.00
$ Per Pay Period:
0.00



Adoption Assistance Maximum of $14,300 per Child
$ Per Pay Period:
0.00
$ 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.
NO OTHER DISABILITY INSURANCES ARE ELIGIBLE FOR REIMBURSEMENT AT THIS TIME. THERE ARE NO EXCEPTIONS.
$ Per Pay Period:
0.00
$ Per Pay Period:
0.00



COBRA (billed through Suffolk County)
Maximum enrollment equals cost of coverage
$ Per Pay Period:
0.00
$ 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


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