2024 Flexible Spending Enrollment Form

Thank you for enrolling! If you need assistance or have questions, please call our Benefits Administration Department at 601-987-3025
Employee Name (required)
 
 
 
 
 
 
 
 
 
 

Do you agree and understand that:

 

Elections cannot be changed during the Plan Year unless there is a change in the family status (marriage, divorce, death of a spouse or child, birth or adoption of a child or a change in spouse’s condition of employment: i.e., becomes employed, unemployed, or changes employers).

 

The opportunity to change my benefit elections for the following Plan Year will be given to me prior to each Plan Year. Benefit selections will continue from one Plan Year to the next without completing a new election form. However, if I wish to make a change or decline further participation for the next Plan Year, a new election form is required.

 

Salary reduction for the Medical and Dependent Care Expense Reimbursement programs will be credited to my “Flexible Spending Account” and the employer will reimburse me during the Plan Year as I submit paid documentation for incurred expenses, for approved un-reimbursed medical and/or dependent care expenses. I further understand that any amount remaining in my “benefit bank” as of March 2024 will be forfeited to the
employer.

 

The employer may have to reduce or cancel the amount of my salary reduction or otherwise modify this agreement to satisfy new provisions of the Internal Revenue Code as they may occur during the plan year. Should I terminate my employment and the reimbursements I have received are greater than the amount that has been deposited into my Flexible Spending Account, I agree to reimburse the difference to People Lease.

Elections

Having selected the benefits checked below, I hereby elect to be reimbursed for the indicated expenditures and authorize my employer to reduce my gross compensation per pay period in the total amount stated below in conformity with Section 125 of the Internal Revenue Code.

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