The Bailey Financial Group FSA/HRA Enrollment

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Note: When completing your enrollment form, it is IMPORTANT to please carefully read each text field and any notes associated with the text field. Please complete as specified. Should you have any questions, please contact IntegraFlex Customer Service at: (208) 287-0310 and one of our customer service representatives can assist you.

** Indicates Required Fields.

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Employer Information
Employee Information

Note: Please provide us with your best contact number and email address, so we may contact you regarding your account, if needed.

Note: Your personal information and email are kept private and secure within IntegraFlex's system. We DO NOT disseminate to any Third Party's unless we have your specific written consent. We solely use your email address for communication purposes regarding your benefit account(s). We will email to you correspondence such as: Quarterly Account Balance Statement, Receipt Notification Request when verification of a debit card transaction is needed, when your claim has been processed letting you know of reimbursement, etc.

PLEASE READ AND INITIAL THE FOLLOWING STATEMENT

I understand that on or after the first day of the HRA plan year, I cannot change or revoke this agreement unless I have had a qualified event under IRS rule. (May include marriage, birth, adoption, divorce or death) I understand and agree to submit only those charges eligible for reimbursement under Section 105/106 and Section 213D of the IRS code. I also agree to repay the plan for any charge submitted but not approved or eligible.

Note: Please specify your FSA elections in an Annual amount. If not electing, please place a "0" in the text field.

PLEASE READ AND INITIAL THE FOLLOWING STATEMENT

I understand that on or after the first day of the FSA plan year, I cannot change or revoke this salary redirection agreement unless I have had a qualified event under IRS rule. (May include marriage, birth, adoption, divorce or death) I understand and agree to submit only those charges eligible for reimbursement under Section 125 and 213D of the IRS code. I also agree to repay the plan for any charge submitted but not approved or eligible.

PLEASE READ AND INITIAL THE FOLLOWING WAIVER STATEMENT

By signing this FSA Waiver, I certify that the features and benefits under a 125 Flexible Benefits Plan have been explained to me. I am electing to Waive all pre-tax benefits under the plan on or after the first day of the plan year and understand that I cannot change or revoke this Waiver and may be prohibited from participation in this plan until the open enrollment period for the following year or unless I have had a Qualifying Event (May include: marriage, birth, adoption, divorce or death), as defined by the IRS.

Spouse/Dependent(s) Information

Note: When entering spouse and/or dependent(s) information, you MUST under IRS regulation enter their Full Social Security Number and Date of Birth. If this information is not provided, we CANNOT process claims for a spouse and/or dependent(s) under the Rules of the IRS.

Note: For an additional debit card for a Spouse and/or Dependent(s). Please contact IntegraFlex Customer Service to request additional cards. Dependents MUST be 18 years of age for debit card eligibility.

Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Dpendent 6
Dependent 7
Bank Account Information For Direct Deposit of Claim Reimbursement Requests

PLEASE READ AND INITIAL THE FOLLOWING STATEMENT

I hereby authorize IntegraFlex to initiate credit entries to my account as indicated below and the depository named below, hereinafter called DEPOSITORY, to credit the same to such account. I further authorize IntegraFlex to reverse any credit entry that IntegraFlex makes to my account to the extent that IntegraFlex reasonably believes such entry was made in error.

Account Information

Note: Please take great care to make sure when entering your Routing and Account numbers that you've entered them correctly. This information is extremely important when we go to Direct Deposit your reimbursement to the bank account you specify.

PLEASE READ AND INITIAL THE FOLLOWING STATEMENT

This authority is to remain in full force and effect until IntegraFlex has received written notification from me of its termination in such time and in such manner as to afford IntegraFlex and DEPOSITORY a reasonable opportunity to act on it. I understand this authorization is for reimbursements from my employer sponsored Cafeteria plan.

PLEASE READ AND SIGN THE FOLLOWING STATEMENT

By electronically signing I am signifying my understanding and acceptance of the responsibilities and requirements associated with a Section 105/106 and Section 213D Health Reimbursement Account Plan. I further understand that, though I may have completed separate enrollment forms for the insurance policies to which I have applied, this enrollment does not constitute acceptance by the companies to which I have applied. Any previous agreements under any other Health Reimbursement Account Plan are hereby revoked.

Date of Signature

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