Shore Lodge HSA / Limited FSA Enrollment

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.

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Employer Information

Plan Effective Date**

Hire Date**

Medical Enrollment**

Note: 2019/2020 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: $3,500 (2019) / $3,550 (2020)
- Family: $7,000 (2019) / $7,100 (2020)
- 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 (2019) / $1,400 (2020)
- Family: $2,700 (2019) / $2,800 (2020)

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

- Individual: $6,750 (2019) / $6,900 (2020)
- Family: $13,500 (2019) / $13,800 (2020)

Enrolling in Limited-Purpose FSA?**

Yes

Note: Please specify your elections in an Annual amount. If not electing, please place a "0" in the text field. Limited FSA monies can ONLY be used toward Dental and Vision Expenses; along with expenses that are "above" the medical HSA plan deductible. When enrolled in an HSA, your medical and prescription expenses MUST be run through your HSA account.

Dental and Vision FSA Annual Amount $**

Dependent Care FSA Annual Amount $**

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 Section 213D of the IRS code. I also agree to repay the plan for any charge submitted but not approved or eligible.

Please Initial**

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.

Please Initial FSA Waiver**

Employee Information

First Name**

M.I.

Last Name**

Gender**

Male

Female

Social Security Number**

Date of Birth**

Marital Status**

Physical Address**

City**

Zip Code**

Mailing Address

City

Zip Code

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

Best Contact Number**

Email address**

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.

Add Spouse?**

Yes

Spouse

Relationship**

First Name**

M.I.

Last Name**

Gender**

Male

Female

Social Security Number**

Date of Birth**

List any disabled dependents

Notes

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. 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 Savings Account Plan are hereby revoked.

Type Your Full Signature**

Date of Signature

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