Form 107 003 PDF Details

The 107 003 form serves as a critical tool for employees wishing to manage their healthcare expenses more efficiently through a Flexible Spending Account (FSA) for the 2008 plan year. Designed specifically for active employees who are either newly hired or participating during Open Enrollment, this form facilitates enrollment in a program that offers a pre-tax benefit to save money on eligible healthcare costs. The enrollment process, outlined with simplicity and clear directives, encourages participants to enroll online, emphasizing the convenience of digital submission. Contributions to this account are meticulously planned, allowing an individual to designate a monthly deposit that aligns with their projected healthcare expenses for the year, capped at an annual maximum of $5,000. This limit remains constant even if an employee’s spouse also contributes to a Healthcare FSA, ensuring a unified contribution threshold across similar plans. Importantly, the form underlines the permanence of contribution decisions within the plan year, barring qualified status changes, and emphasizes the necessity of thoughtful participation; unclaimed funds by the specified deadline result in forfeiture. Administered by Application Software, Inc. (ASIFlex), this program underscores a commitment to providing employees with an informed path towards financial prudence in healthcare spending while navigating through federal regulations and potential tax implications. Detailed in a structured format, the form includes sections for personal and dependent information, although dependent details are not required for FSA enrollment, reinforcing its focus on the employee's individual healthcare expense management.

QuestionAnswer
Form NameForm 107 003
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshcfsaenrollment pebb oregon fsa form

Form Preview Example

PEBB Healthcare Flexible Spending Account Enrollment Form

Active Employee

2008 Plan Year – Instructions

Enroll online at https://pebb.benefits.oregon.gov/members

Complete this form to enroll for a Healthcare Flexible Spending Account (FSA) for 2008, as a newly hired employee or during Open Enrollment.

•Effective date for Open Enrollment is January 1, 2008. Effective date for a mid-year enrollment is the first of the month following receipt of the appropriate forms.

•If you terminate employment, no contribution to your account will be taken from your final pay.

•Application Software, Inc. (ASIFlex) administers the FSA plans. If you have any questions about your FSA reimbursement or account balance, contact ASI at 1-800-659-3035 or www.asiflex.com. Detailed information is available in the PEBB Benefit Handbook, on-line at www.oregon.gov/DAS/PEBB or from ASI.

SECTION A - EMPLOYEE INFORMATION

•Complete each item in this section.

SECTION B - CONTRIBUTION AMOUNT

•Total Year Election: Calculate your monthly deposit based on the effective date of enrollment and the number of calendar months remaining in the year (Open Enrollment is 12 months). If you are an Oregon University member and do not anticipate working 12 months, contact your university benefit representative for additional information.

OThe annual maximum is $5,000.

OIf you participate in the Healthcare FSA and your spouse also has a Healthcare FSA through the state of Oregon or another employer, your individual contribution limit is still $5,000.

SECTION C – DEPENDENT INFORMATION

You do not need to list your dependents under the Healthcare FSA.

SECTION D – EMPLOYEE SIGNATURE AND AUTHORIZATION

•Read this section carefully. Sign and date the form.

•Make a copy for your records, and submit the completed form to your agency/university payroll, personnel or benefits office.

1

107-003 (10/01/07)

Healthcare Flexible Spending Account Enrollment Form

Active Employee 2008 Plan Year

SECTION A - EMPLOYEE INFORMATION

 

NEW EMPLOYEE

 

 

HIRE DATE :

 

 

 

 

OPEN ENROLLMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST

 

 

FIRST

 

 

 

MI

ID NUMBER (SSN, OUS#, Benefit #)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF BIRTH (MM-DD-YYYY)

 

 

 

GENDER

FEMALE

MALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESIDENCE ADDRESS

 

 

New Address

 

CITY

 

STATE

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COUNTY

 

HOME PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS (if different from above)

New Address

 

AGENCY

 

WORK PHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-MAIL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION B - CONTRIBUTION AMOUNT

 

 

 

 

 

 

 

 

 

 

See Instructions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Monthly

 

 

Number of Months

 

 

Maximum Allowable Election for the year is $5,000

 

 

 

 

 

Plan

 

 

Contribution

 

 

 

 

(Monthly Contribution x Number of Months)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEALTHCARE FSA

$

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION C - DEPENDENT INFORMATION

 

 

 

 

 

 

 

 

 

 

No dependent information is required.

 

 

 

 

 

 

 

 

 

 

SECTION D - EMPLOYEE SIGNATURE AND AUTHORIZATION

 

 

 

 

 

 

 

I verify that I am eligible to participate in the PEBB Healthcare FSA.

 

 

 

 

 

 

 

I agree:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• Not to deduct or claim credit for any of the expenses reimbursed through an FSA on my individual income tax return.

 

I understand that:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• FSAs are subject to current federal government regulations and to any future tax changes required by the federal

 

 

government.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• The elections I have made are in effect, as long as PEBB eligibility requirements are met for the 2008 plan year.

• If I do not incur the anticipated expenses during the plan year or grace period and I do not file for reimbursement by

 

 

March 31, 2009, I forfeit my remaining balance.

 

 

 

 

 

 

 

• I can change my contribution midyear only if I experience a qualified status change. The request must be consistent

 

 

with the qualifying status change.

 

 

 

 

 

 

 

 

 

 

• This is an annual account I must enroll during Open Enrollment to continue participation from year to year. I

 

 

determine my deposits for the next year with each enrollment.

 

 

 

 

 

 

 

I have read the PEBB Benefit material. I understand the limitations and qualifications of this program.

 

 

 

___________________________________________

 

 

 

_____________________

 

 

 

Employee Signature

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PEBB Use Only

 

 

 

 

 

 

 

Approved By: (initial)

 

Date:

Approved Effective Date:

 

PDB Updated by: (initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

107-003 (10/01/07)

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With regards to the fields of this particular document, this is what you need to do:

1. Fill out your Form 107 003 with a number of essential blanks. Collect all the information you need and make sure not a single thing omitted!

Step no. 1 for submitting Form 107 003

2. The third stage is to fill in the following blanks: SECTION A EMPLOYEE INFORMATION, OPEN ENROLLMENT, LAST, FIRST, ID NUMBER SSN OUS Benefit, DATE OF BIRTH MMDDYYYY, RESIDENCE ADDRESS New Address, MAILING ADDRESS if different from, SECTION B CONTRIBUTION AMOUNT See, GENDER FEMALE MALE, CITY, STATE, ZIP, COUNTY, and HOME PHONE.

Stage no. 2 for filling out Form 107 003

Always be really careful while completing FIRST and GENDER FEMALE MALE, because this is the part where most users make mistakes.

3. Completing I have read the PEBB Benefit, Approved By initial Date Approved, and PEBB Use Only is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

I have read the PEBB Benefit, Approved By initial Date Approved, and PEBB Use Only inside Form 107 003

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