Open Enrollment Re-enrollment Instructions – (Available during Open Enrollment) If you are a half-year 2016 FSA participant, re-enroll for fiscal 2017 benefits online during the Open Enrollment period.
* Re-enrollment Screen Shots – (Available during Open Enrollment) These screen shots show you what you’ll see as you re-enroll in FSA benefits online.
2016 Enrollment Form – If you are hired on December 5, 2015, or later, use this form to enroll in partial year benefits. Return the completed form to your Payroll Coordinator.
DCAP Claim Form : Use this form to submit dependent care-related claims for reimbursement.
Flexible Spending Account Status Change form – use this form to increase or decrease your contribution to, or terminate your election in Flexible Spending Account within 30 days of a qualifying event during the plan year. You must submit this form with supporting documentation within 30 days of the qualifying event: change in legal marital status; change in number of dependents; change in employment status; change in work schedule that affects your eligibility for the program; change in dependent’s FSA eligibility, or a judgment decree pertaining to your spouse or child.
Flexible Spending Account Appeal Form - If you disagree with a denied claim or adverse decision regarding your HCSA or DCAP benefit (e.g. claim for reimbursement denial, eligibility for pre-tax benefits or election change), and you feel this denial was made in error you may file a formal appeal by using this form.
This information provided by the Group Insurance Commission .