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A. EMPLOYEE INFORMATION All information required for Section A

NAME OF EMPLOYER
EMPLOYEE NAME
ENTER LAST 4 DIGITS OF YOUR SOCIAL SECURITY #
YOUR DATE OF BIRTH
EMAIL ADDRESS
A confirmation will be emailed to you. Retain it for your records to preserve your tax free benefits.
STREET ADDRESS
CITY
STATE
ZIP
DAY TIME PHONE NO.
B. BENEFIT ELECTION
Enter Your Contribution Amount(s) for the Plan Year - not Monthly Deductions
(Note: Not all benefit options may be available to you. Review your Open Enrollment materials or contact your H.R. Department.)
FLEXIBLE BENEFIT PLAN
HEALTH CARE REIMBURSEMENT ACCOUNT ("HCRA")
Contact your Employer about their Contribution Limits
$
DEPENDENT CARE REIMBURSEMENT ACCOUNT ("DCRA")
Up to $5,000 for 2008
$
COMMUTER BENEFIT PLAN
MASS TRANSIT
Up to $1,380 ($155 per month) for 2008
$
PARKING
Up to $2,640 ($220 per month) for 2008
$

INSTRUCTIONS: Print and submit a signed version to your HR Department OR email them a copy for payroll deduction purposes, no signature required if emailed. Failure to follow the instructions may delay or jeopardize your participation. This online form is intended to comply with "E-Sign" (Pub. L. No. 106-229, June 30, 2000).
(Note: For HRA and HSA enrollment, please use special enrollment form available from the FORMS section or your H.R. Department.)