Medical Flexible Spending Account Application
I have read and agree with
terms
and conditions.
I Agree
I Disagree
*
Employer:
*
SS #:
*
E-mail
*
Last name:
*
First Name:
*
Address
:
*
City:
*
State
*
Zip
*
Home Phone:
*
Work Phone
*
Bank Name:
*
Type of account:
Select One
Checking Account
Savings Account
*
Routing Number
:
First 9 Numbers on left bottom of check
*
Bank Account #
:
*
I am paid:
Select One
Weekly
Biweekly
Semimonthly
Monthly
I elect to participate and designate to redirect per payperiod
pre-tax
Sign and Date
Please Print the form and fax to 800-449-7501 or
615-292-2406