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Welcome to the IntegraFlex Online Enrollment Form!

Please make sure you have all your and Spouse's and/or Dependent's information before starting the enrollment process.

Please enter the required information starting with your

EMPLOYERS NAME

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Welcome!

What plans are we enrolling in today?

You can't enroll and waive on the same submission! Please enroll first, then submit a second form to waive a specific plan.

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Let's get some basic information first

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What is the start date for the plans you are waiving?

What is the start date for the plans you are enrolling in?

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Just a few more things we need to know

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**Please Note**

A Physical Address MUST be Provided when Enrolling into an HSA.
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Direct Deposit?

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DISCLAIMER INFO:

CRA, DCA, FSA and HRA

 

I hereby elect to participate in a Tax-advantaged benefit plan agreeing to be bound by all terms, conditions and limitations of the Plan and any and all separate plans, contracts and documents made a part hereof. I agree to have my gross salary reduced by the amount of the cost of the benefits selected and that my elections indicated above are binding. I understand that my elections cannot be revoked or changed and/or my group medical insurance canceled unless under a qualified event as described within the Plan.

I understand and agree to submit only those charges eligible for reimbursement under Section 125, Section 129, Section 132 and Section 213D of the IRS code. I also agree to repay the Plan for any charge submitted but not approved or eligible. I understand that any unused balance in the Tax-advantaged benefit plan at the end of the Plan Year may be forfeited.

I have reviewed my company's Tax-advantaged benefits Summary Plan Document and understand the terms. I understand that I must keep copies of all my Itemized Billings Statements and/or Explanation of Benefits (EOBs) and can be asked to submit them at any time throughout the Plan Year. I also agree that if I cannot produce a copy of the requested documentation the claim will be deemed ineligible and I will have to refund the Plan for the total expense when a reimbursement has taken place.

By electronically signing the salary redirection form I am signifying my understanding and acceptance of the responsibilities and requirements associated with a Tax-advantaged benefit plan. I further understand that, though I have completed separate enrollment forms for the insurance policies to which I have applied, this form 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 Tax-advantaged benefit plans are hereby revoked.

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DISCLAIMER INFO:

HSA

 
By electronically signing, I certify that:
  • I am, or will be covered by a qualified High Deductible Health Plan (HDHP), I am not enrolled in Medicare or covered under other health insurance that is not compatible with an HSA, and I may not be claimed as a dependent on another person’s tax return (excluding spouses per the IRS).
  • Avidia Bank is hereby appointed to serve as custodian of my Health Savings Account.
  • I have reviewed and agree to the following Agreements and Disclosures; Deposit Account Agreement, Health Savings Custodial, Funds Availability, Electronic Funds Transfer, Check 21. Truth in Savings and Privacy Statement.
  • Within seven (7) calendar days from the date I open this HSA, I may revoke authorization for opening the account by mailing a written notice to Avidia Bank, P.O. BOX 370, Hudson MA 01749.
  • To help the government fight the funding of terrorism and money laundering activities, Federal Law requires that all financial institutions obtain, verify and record information that identifies each person who opens an account. What this means to you: when you open an account we will need you and your authorized signer to provide name, street address, date of birth and other information that will allow us to identify you and your authorized signer. We may also ask to see your driver’s license or other identifying documents.
  • I understand account statements are delivered electronically and I can change delivery preference once enrolled for online access
  • The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me).
  • I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding.
  • I am a U.S. citizen or other U.S. person.
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DISCLAIMER INFO:

Waiver of Participation

 

By signing this Waiver, I certify that the features and benefits under a Tax-advantaged benefit 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.

I have been given the opportunity to enroll in the Healthcare Reimbursement, Dependent Care Reimbursement and Premium Only Plans but I DO NOT WISH to participate.

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