Capstone Management Services, Inc. FSA / HSA 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

Note: If you are enrolled in the Health Savings Account (HSA) Saver Medical Plan, you will want to contribute to an HSA bank account. If you are enrolled in the Gold Medical Plan, you CANNOT fund an HSA, you can ONLY fund and participate in a Flexible Spending Account (FSA).

HSA Per Payroll Contribution Election

Note: Please specify your HSA election in a per payroll amount. If enrolled in an HSA, you CANNOT participate in the FSA.

Note: 2018/2019 IRS Maximum Contribution and Out-of-Pocket Limits for Health Savings Accounts (HSAs) and High Deductible Health Plans (HDHPs) are as follows:

HSA Annual Maximum Contributions:

- Individual: $3,450 (2018) / $3,500 (2019)
- Family: $6,900 (2018) / $7,000 (2019)
- HSA Catch-Up Contributions (Age 55 or Older): An additional annual amount of $1,000 can be contributed to the HSA Annual Maximum Contributions.

HDHP Minimum Deductible Amounts:

- Individual: $1,350 (2018) / $1,350 (2019)
- Family: $2,700 (2018) / $2,700 (2019)

HDHP Maximum Out-of-Pocket Amounts (Deductibles, Co-payments, and other amounts, but not premiums):

- Individual: $6,650 (2018) / $6,750 (2019)
- Family: $13,300 (2018) / $13,500 (2019)

FSA Annual Contribution Election

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

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 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.

Spouse/Dependent(s) Information

Note: When entering spouse and/or dependent(s) information, you MUST under IRS Rules enter their Full SSN and DOB. 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
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 223 Health Savings Account Plan and Section 125 Flexible Spending 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. I understand and agree that an amount equal to what I have calculated will be deducted from each of my qualified pay periods from now through the end of the plan year. This amount shall continue for each pay period unless this agreement is amended or terminated. I understand the actual amount of my take home pay may increase or decrease depending upon the coverage or elections I have made. Any previous agreements under any other Health Savings Account Plan and/or Flexible Benefits Plan are hereby revoked.

Date of Signature

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