All full-time CICL or part-time employees hired before January 1, 2007 are required to complete this form to indicate their choice for how their annual benefit allowance will be utilized.

 

This form is to be completed even if your selection is to decline participation in all optional benefit coverages.  If you select to participate in any of the optional coverages, you will be required to complete the appropriate enrollment form.  If this applies to you, please select the appropriate enrollment form from the "Feedback/Request Forms" section at the ChoicesHR.com website.

 

If you have any questions, or would like to request a hardcopy of the form, contact Human Resources at 937/898-2220.

 

 

This is an enrollment option for you to enroll in the Chard-Snyder Flexible Spending Account (FSA) for the 2009 calendar year.  If you would like to complete a hardcopy of the enrollment form, contact Human Resources.  The following is a description of the different options that an employee can select.

 

                                      Plan Election Description

 

Healthcare - Flexible Spending Account (FSA):  This is a pre-tax contribution that you make equal installment from each pay to reach the total amount you have selected.  This account is used to cover out-of-pocket expenses for medical, dental, and vision related expenses.  The total maximum amount that can be contributed annually is $3,500.00.

 

Dependent Care - Flexible Spending Account (FSA):  This is a pre-tax contribution that you make equal installment from each pay to reach the total amount you have selected.  This account is used to cover out-of-pocket expenses for child care or adult daycare expenses.  The total maximum amount that can be contributed annually is $5,000.00 if you are married filing jointly or single.  If you are married and filing separately, the maximum annual amount you can contribute is $2,500.00.

 

Debit Card:  The "Benny" prepaid benefits card is available for use for the Healthcare FSA. 

 

 

This is an enrollment option for you to select dental insurance for you and your family.  If you would like to complete a hardcopy of the enrollment form, or you have questions or concerns, contact Human Resources. 

This is an enrollment option for you to select additional long term disability insurance for you.  If you would like to complete a hardcopy of the enrollment form, or you have questions or concerns, contact Human Resources. 

This is an enrollment option for you to select additional term life insurance for you and your family.  If you would like to complete a hardcopy of the enrollment form, or you have questions or concerns, contact Human Resources.