Feedback/ Request Forms : choiceshr.com

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.

2010 Flex Spending Enrollment

*Your Email Address:

If you do not have an email address to insert in the previous question, please insert the following email address: employee@cicl.com

First Name:

   * Last Name

   * Home Phone #

   * Work Phone #

   * Social Security #

    Email Address

   * Home Address

   * City

   * State

   * Zip code

   * I select to participate in the Healthcare FSA

   * The annual contribution is (if you are not particiating in the program, place a "0" for the amount)

   * I select to particiate inthe Dependent Care FSA

   * The annual amount of my contribution is (if I am not participating in the program, place a "0" for the amount)

   *

Do you want to request a "Benny" card ( there is a $20.00 fee for the "Benny" card)

I hereby authorize CICL to deduct from my compensation the required contributions for the amount(s) I have selected above. Available upon request are the authorizations and acknowledgements provided by Chard-Snyder for each plan elected above. I also acknowledge the receipt of the HIPAA Privacy Notice provided by Chard-Snyder and/or CICL. For additional information on authorizations or HIPAA, go to www.chard-snyder.com.

To confirm your selection and provide an electronic signature please insert your employee number and the last four (4) digits of your social security number.

    Would you like for someone from Human Resources to contact you about your application?