NEW YORK STATE FLEX SPENDING ACCOUNT A State employee benefit that puts money in your pocket
HEALTH CARE SPENDING ACCOUNT	ENROLLMENT FORM
PLEASE PRINT

CHECK ONE OF THE FOLLOWING:  New Enrollment        Re-Enrollment         New Hire         Change in Status			Social Security Number:
Last Name:		First Name:		Middle Initial:
Home Address Street:		Home Address City:	State:	Zip Code:
Work Phone:	Home Phone:	Payroll Cycle (Administrative or Institutional):	Annual Salary:
Department ID:	Agency or Facility Name and Address:		Negotiating Unit Code

COMPLETE IF APPLICABLE:	If new hire, employment start date:   __________/__________/__________ If change in status, date of qualifying event:   __________/__________/__________
CHECK ONE:  I expect to receive the following number of regular paychecks during the 2001 Plan Year: 26        21 (SUNY & DOCS only)        20 (SUNY only)        11 (SUNY Only)        10 (SUNY Only)        Other  (Please specify):  _______________

INSTRUCTIONS:

1. Complete the worksheet provided in your enrollment kit before deciding how much you wish to contribute through tax-free salary deductions.
2. Indicate the annual amount you wish to have deducted from your salary by completing the section below.
3. If you have questions, consult your enrollment kit or call Fringe Benefits Management Company at 1-800-358-7202.
4. If this is a new enrollment or re-enrollment, submit your completed form to your Health Benefits Administrator for approval by the end of the open enrollment period.
5. If you are a new employee, submit your completed form to your Health Benefits Administrator within 30 calendar days of your employment start date. You will be eligible for coverage once you have served 60 consecutive calendar days of State service.
6. If this is a change in status, submit your completed form within 30 calendar days of the qualifying event to: Fringe Benefits Management Company, Attention CIS Department, P.O. Box 1878, Tallahassee, Florida 32302-1878.

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SELECT ONE:
	I wish to contribute $__________ on an ANNUAL BASIS for the 2001 Plan Year. (If you also enroll in the HOP or SLEP program, the combined total of both contributions may NOT exceed $3,000. The minimum allowable annual contribution is $150.)
	I only wish to enroll in the Health Care Spending Account in order to deposit my HOP or SLEP program contribution.

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IMPORTANT

• I understand that by completing and signing this form, I authorize the State to deduct the Health Care Spending Account contributions in pre-tax dollars from my paycheck, which can only be used to reimburse me for eligible health care expenses incurred during my period of coverage.
• I understand that if I exceed the maximum contribution limit as a result of my enrollment in either the HOP or SLEP programs, my payroll deduction will be adjusted to limit my total annual contribution to no more than $3,000.
• I understand any amount remaining in my Health Care Spending Account not used during this Plan Year will be forfeited since it cannot be carried forward to the next Plan Year.
• I understand that funds in my Health Care Spending Account cannot be used to reimburse expenses covered by the Dependent Care Advantage Account.
• I understand that expenses for which I am reimbursed cannot be deducted on my income tax return.
• I understand that the amount of salary contribution will continue in effect throughout the next calendar year, unless I terminate employment or file an approved Change in Status with the Plan Administrator within 30 calendar days of the event or before the end of the calendar year.
• I understand and agree that my employer and Fringe Benefits Management Company, the Plan Administrator, will not incur any liability resulting from either my participation in the Health Care Spending Account or my failure to sign or accurately complete this enrollment form.

By signing this form you certify that you expect to receive the number of paychecks listed above. If appropriate, decrease the number to allow for anticipated unpaid leave, or for planned retirement, or any other anticipated leave.

EMPLOYEE SIGNATURE:

Date Signed:

HBA Initials and Date:

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FBMC USE ONLY

Data Entry:

Verification:

Scanned:

Indexed:

Special Notes: