Health Plan - Flexible Spending Enrollment Form

I'm a new employee, hired in the last 30 days.
(This will enroll you in the current year only. For next year you must re-enroll during Open Enrollment.)
I've had a qualifying life event and need to update my information and enroll.

ADP Employee ID (Located on check stub)*:

Primary e-mail Address*:

Work e-mail :

First Name *:

Middle Initial:

Last Name*:

Street Address*:

Apartment #:

City*:

State *:

Zip Code *:

Domestic Partnerships

Do you have a domestic partner (registered with Clerk of Council) *:

YesNo

Benefit Election

How often are you paid? *:

Bi-WeeklyWeekly

Health Care Expenses (OPCD and OPSO only)

Calendar year benefit for Medical, Dental, Vision, etc.

Maximum election of $3,050
Elect lesser amount
Do NOT elect benefit

Dependent Care Expenses (OPCD and OPSO only)

Calendar year benefit for Day Care, After School Care or Adult Day Care

Max election of $5,000 per family
Max election of $2,500 if married and file separate tax returns
Elect lesser amount
Do NOT elect benefit

Commuter Parking Expenses (OPCD and OPSO excluded)

Monthly benefit (Must enroll by 10^th of each month)

Max election of $300 (Monthly)
Elect lesser amount
Do NOT elect benefit

Commuter Transit Expenses (OPCD and OPSO excluded)

Monthly benefit (Must enroll by 10^th of each month)

Max election of $300 (Monthly)
Elect lesser amount
Do NOT elect benefit

Signature and Acknowledgement

View Terms and Conditions

This agreement will remain in effect for the Plan Year unless changed for reasons stated in the terms and conditions of the Plan. By typing my name, I certify that I have examined this agreement and understand and agree to comply with the terms and conditions of the Plan. If this is a change in status, I certify that this change is consistent with the qualifying event. I agree to hold UnitedHealthcare Benefit Services and my employer harmless from any liability to my participation in this plan. *:

Today's Date *:

Flexible Spending Account Plan for January 1, 2024 to December 31, 2024

OPCD and OPSO employees ONLY:

For Healthcare and/or Dependent Care Benefits in United Healthcare's Flexible Spending Account Plan:

For Commuter Benefits

Eligibility

What brings you to this form today?:

Employee Information

Domestic Partnerships

Benefit Election

Signature and Acknowledgement

Where Y'At

Search and Find Permits

Brake & Bike Tags

Contractor Info For Residents

Permits & Licenses

Permitting Help & Support

Flexible Spending Account Plan for January 1, 2024 to December 31, 2024

OPCD and OPSO employees ONLY:

For Healthcare and/or Dependent Care Benefits in United Healthcare's Flexible Spending Account Plan:

For Commuter Benefits

Eligibility

What brings you to this form today?:

Employee Information

Domestic Partnerships

Benefit Election

Signature and Acknowledgement

Where Y'At