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 CODE
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 2005
$
COMMUTER BENEFIT PLAN
MASS TRANSIT
Up to $1,260 ($105 per month) for 2005
$
PARKING
Up to $2,400 ($200 per month) for 2005
$

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).