Flexible Spending Account Administration Guide and Requirements Gathering DocumentFor: (Client Name)

Table of Contents

Client Information..............................................................................................................................4Non-Discrimination Testing......................................................................................................6

Funding Process..................................................................................................................................8Overview..........................................................................................................................................8Claims Funding and Maintenance Deposit.........................................................................8Check Information........................................................................................................................8Unclaimed Checks........................................................................................................................8Funding Reports............................................................................................................................9Funding Samples..........................................................................................................................9

Methods for posting payroll deductions..................................................................................10Enrollment And Eligibility..............................................................................................................13

Open Enrollment Census.........................................................................................................13Online Enrollment Census (Demographics Only)...........................................................13Paper Enrollment Form............................................................................................................13Ongoing Eligibility Method......................................................................................................14

Plan Document..................................................................................................................................15FSA Plan Design................................................................................................................................16

Eligibility requirements (hours per week):.......................................................................16Waiting Period for new employees:.....................................................................................16

Debit Card Requirements..............................................................................................................20Initial Debit Card Distribution................................................................................................20

Employer Reports.............................................................................................................................22Employer Portal Users and Access Levels..............................................................................23Participant Forms.............................................................................................................................24

Claim Reimbursement Form..................................................................................................24Direct Deposit Authorization Form......................................................................................24Health Care Eligible and Ineligible FSA Expenses........................................................24Physician Statement.................................................................................................................24

Participant Communications........................................................................................................25Fees.......................................................................................................................................................25Acceptance.........................................................................................................................................26

Client Information

Client Name: DBA or AKA

Name:Client Address:Client Tax ID:

Number of Benefit Eligible:

Expected Participant Count ___________________

Entity Type (S Corp, C Corp,

LLC): Industry:Tax Year End

Month and Day:State Organized:

Controlled Group:

Yes No

If yes, list Affiliates including Tax ID#

Main Client ContactName:Title:Email Address:Telephone: Secondary Client ContactName:Title:Email Address:Telephone:Broker ContactName:Title:Agency:Email Address:Telephone:Broker will be copied on all implementation, renewal and escalated emails. Check this box if broker should not be copied on these emails: What unique employee identifier will you be using:

SSN Employee ID (must be 9 digits)

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SSN Employee ID (must be 9 digits)

Medical Carrier:

Divisions: Yes NO

List of Divisions:

Timing of Claim Payments

Mailed or faxed claims are scanned and queued for processing within 1-3 business days of receipt. Uploaded claims are immediately available for processing. Once available for processing, claims are typically approved or denied within 2-4 business days. Notifications for denied claims and for claims where more information is required are sent each day for claims processed the prior day. Check and direct deposit files are created three times per week for claims

approved as of prior business day. Checks are mailed next day

Direct deposits are posted same day and available to participants within 1-2 business days after files are loaded.

Eligible Expenses IRS Code 213 eligible and ineligible expense list will be used to determine

eligible expenses. https://www.irs.gov/pub/irs-pdf/p502.pdfClaim Requirements

Claims may be filed through the participant’s online portal, the Benefit Strategies mobile app, or by submitting a paper claim form via secure email, fax or mail. Claims must include only expenses eligible for reimbursement as defined by federal regulations and not previously submitted with a claim. Documentation supporting the claim must be included with each claim filed, such as invoices, Explanation of Benefits (EOB) or Medicare Summary, a copy of both sides of cancelled checks (for dependent care only), or receipts that include the following information:

Patient or dependent name Date of service Description of service Expenses incurred

Note: Claims for dependent care expenses paid in advance of the Service Date will be denied until the service date has passed –

Mid-Year FSA Changes

Mid-year FSA election changes can only be made per IRS qualified events. Changes to elections must correlate with the change in the event. For example, a divorce would constitute a decrease in election, a marriage or birth would constitute an increase in election, as of the effective date of the

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event.Non-Discrimination Testing

Non-discrimination testing is available upon request and subject to a fee. Upon request, client is sent information and forms to complete, including providing census information on all employees. If testing results in election amounts needing to be cutback, the client must provide the cutback amount for each impacted participant to Benefit Strategies so adjustments can be made in our system. Note: Clients are responsible for providing written notification to affected

employees of any election amount and/or deduction changes.

Do you want to have your plan(s) tested for the new plan year?

Yes – please see the materials located HERE for next steps when ready for testing. No

Administering Run Out From Current TPA

If an FSA is already in place and you are changing administration to Benefit Strategies with the start of the new plan year, the outgoing administrator should handle the outgoing plan year run-out and Grace Period option. If the outgoing plan year has the $500 rollover option, rollover balances will need to be provided to Benefit Strategies once the run-out period has ended.

Takeover From Current TPA

Takeover Template

A takeover implementation means Benefit Strategies will take over the administration of your current plan year during the current plan year. Because we will have taken over the administration mid-year, we will then handle the run-out at plan year end, as well as the Grace Period and Rollover options, as applicable. Takeovers can be done at any point in the plan year, up to 31 days prior to the plan year end date. Example: If plan year ends December 31, takeover must happen December 1 or earlier.A fee applies for the takeover implementation.Typically, the outgoing administrator will want a claim filing/debit card black out period so all in-house claims can be settled and final balances provided to Benefit Strategies.The attached Takeover Enrollment census should be used to provide Benefit Strategies, LLC with FSA enrollment information for all current participants if we are taking over the plan mid year. Benefit Strategies will request updated year to date payroll, and claims paid information after the chosen black out period has ended to ensure all information on account is up to date.

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Are you requesting a mid-year takeover implementation?

No Yes –

complete questions to the right

Benefit Strategies must be provided with the following information in a mutually agreed upon format in order to do a takeover:

Enrollment Census Current Balances Year To Date Payroll Deductions Claim History (if this can’t be provided, we are unable to prevent a

claim previously paid by the prior TPA from being submitted to Benefit Strategies and paid out again.)

If you are requesting a mid-year takeover implementation, what is the current plan year end date?

Will the takeover plan year and the new plan year requirements be the same?

Yes No, new plan year differences are:

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Funding Process OverviewBenefit Strategies pays claims three times per week. Claims are paid in advance and clients are invoiced weekly for claims paid the prior week. Claims Funding and Maintenance DepositPlease complete the Claims Funding Agreement and EFT Form (if applicable) and return with this document.

Checks and direct deposit payments are drawn against a Benefit Strategies, LLC bank account.

Check and direct deposit files are created three times per week for claims approved as of the prior business day and sent to fulfillment.

A Claims Funding Request report (invoice for claims paid) is emailed to clients weekly for the prior week’s claims reimbursements.

Funding amounts are due within 2 business days after receipt of the funding request. Payment is made to Benefit Strategies, LLC either by check (Manual Invoice), ACH payment, or EFT debit.

A Maintenance Deposit is required to mitigate the risk of Benefit Strategies paying claims in advance. The Maintenance Deposit is determined by taking total annual elections divided by 26. The Maintenance Deposit remains with Benefit Strategies until the point that the client terminates FSA services. At the time the amount of the Maintenance Deposit will be returned.

The Maintenance Deposit amount is revisited only when a new plan is added or a current plan is dropped, or there is a significant change in enrollment.

Check Information A brief explanation is included with each claim payment check. Participants may contact Customer Service to request a claim

payment check be voided and reissued if the check is lost and has not yet been cashed.

All claim payment checks indicate “Void after 180 Days”. o In our experience, banks will still cash checks after the 180 days

Unclaimed Checks Clients will address the escheatment and/or other handling of unclaimed checks that have reached the 180 day expiration date. No updates to Lightouse1 will be made with regard to unclaimed checks that have expired.

A report of unclaimed checks will be provided upon request.

Funding ReportsA claims funding invoice and claims funding report will be emailed weekly to the financial contact(s) you indicate below. The invoice provides notification of the amount required for funding claims paid the prior week (debit card transactions and claim reimbursement requests)

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as well as any adjustments, and debit card fees (if applicable). The report provides the details to support the invoice.

Client Financial Contacts

Financial ContactName: Title: Email: Phone Number:

Financial ContactName: Title: Email: Phone Number:

Financial ContactName: Title: Email: Phone Number:

Financial ContactName: Title: Email: Phone Number:

Division Subtotals

Funding invoices and/or reports will contain divisional subtotals if applicable.

Funding Samples

Claims Funding Invoice and Detail Sample

Claims Funding Invoice and Detail with Divisions Sample

Methods for posting payroll deductions

Methods for posting payroll deductions. Choose one of the following options: Best Practice for posting payroll deductions is via File Import: Benefit Strategies will import the payroll file to post the deductions. You will be responsible for sending a payroll file each pay period of actual deductions. Payroll files will be expected

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two days prior to deduction date.  This method reduces processing time and minimizes the need for confirmation of changes.

Alternative Method: Anticipated Deductions/Compare Method Benefit Strategies will post anticipated payroll deductions (based on annual election amount divided by pay periods) each pay period. You will be responsible for sending a payroll file each pay period of actual deductions. We will run a comparison and correct any posted deductions needed. In comparison to the recommended best practice, this method often has longer processing times and may increase the need for confirmation of changes.

*For both payroll file methods, it is recommended to send a full eligibility file. Please see Enrollment & Eligibility section for more information.

Benefit Strategies payroll file spec will be completed and sent:From Client: From Vendor: Frequency(s): File contact Name: File contact Phone: File contact Email:

Testing needs to be completed with Benefit Strategies prior to the Go Live date. Vendors sending files often require a long lead time. Please send the payroll file spec to your vendor immediately and confirm their ability to comply with the testing timeline. For additional details on Payroll file testing or specifications, please contact dataservices@benstrat.com for assistance.

Payroll system rounding Standard (anytime deduction is 3 decimals places .005 or higher will round up, less than

.005 will round down. Ex. $25.274 will round down to $25.27 and $25.275 will round up to $25.28)

Up (Anytime deduction is 3 decimal places, will round up. Ex. $25.271 will round to $25.28)

Down (Anytime deduction is 3 decimal places, will round down. Ex. $25.279 will round to 9

$25.27)

Are deduction adjustments made with the first pay period or last?

First pay period Last pay period

Submission of Payroll Calendar

To ensure employee payroll contributions are in alignment with anticipated scheduled payroll deductions, please include a copy of your new payroll calendar.

Please provide a payroll calendar or use the following template located HERE,

Will you be providing multiple payrolls? If so, please see additional tabs in the payroll calendar.

LOA - Leave of Absence

Please see attachment for detail explanations of the following 3 options that are available.

Choose one of the following options, if applicable: Prepay Pay as you go Pay upon return

FSA Continuation Coverage Information

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Is your company subject to FMLA? Yes No

Is your company subject to COBRA? Yes No

Are you aware that FSAs are COBRA eligible plans and the rules for determining how much of the FSA can be COBRA'd? Yes No

Is COBRA administration

handled in-house, by Benefit

Strategies, or other?If other administrator:

Name:Address:

Telephone Number:

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Enrollment And Eligibility

Open Enrollment Census

Online Enrollment Census (Demographics Only)

Paper Enrollment Form

The attached Open Enrollment census should be used to provide Benefit Strategies, LLC with FSA enrollment information after your Open Enrollment period has ended. 

The attached Online Open Enrollment Census should be used if offering online open enrollment with Benefit Strategies.  Once the census is complete and returned follow up directions will be provided for you to send to participants to enroll directly online.  This option requires a 6 week window prior to your effective date.

Open Enrollment Start Date:

Open Enrollment End Date: 

The attached Paper Enrollment from should be used to provide Benefit Strategies, LLC with FSA enrollment information after your Open Enrollment period has ended.

Please note: Enrollment information is due to Benefit Strategies, LLC by the below time frame in order to ensure debit cards are mailed prior to the plan start date:January effective dates: No later than December 1st. All other months: At least 20 days prior to the plan start date.Enrollments received after this date may still have cards mailed prior to the start date but we are not able to guarantee it.

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Ongoing Eligibility Method

How will we be receiving on-going eligibility:From Client: From Vendor: Frequency(s): File contact Name: File contact Phone: File contact Email: FTP Address:

IMPORTANT: Testing needs to be completed with Benefit Strategies prior to the Go Live date. Vendors sending files often require a long lead time. Please send the eligibility file spec to your vendor immediately, and confirm their ability to comply with the testing timeline. For additional details on eligibility file testing or specifications, please contact dataservices@benstrat.com for assistance. *If recurring eligibility file is being sent consumers ability to make profile changes will be turned off. Client direct entry in administrator portal:

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Plan DocumentPlan DocumentsBenefit Strategies will provide a Section 125 Plan Document and a Summary Plan Description. Choose one of the options.

Benefit Strategies provide new plan document (chose this if you have never offered an FSA before)

Plan Name:

Use standard naming convention (Client Name Section 125 Plan Document)

Other Name:Plan Number:

Use standard plan number, 501 Other: Number

Benefit Strategies provide re-stated plan document (chose this if you currently offer an FSA Plan)

Effective date of current plan document:Name of current plan document:Current Plan Number in plan:

Benefit Strategies is not responsible for plan document or Summary Plan Description

Information needed for plan document creationWill FSA eligible employees also be offered a Health Savings Account (HSA)? Yes NoWill FSA eligible employees also be offered a Health Reimbursement Account (HRA)? Yes No Do employees have pre-tax deductions?

No Yes (complete below)

Medical Dental Vision HSA contributions LTD STD Other:

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How is the pre-tax deduction election made:

Automatic election – employee must opt out to un-elect Upon hire and election carries over year to year Upon hire and employee re-elects annually

Are employees offered cash back in lieu of benefits

No Yes – Describe:

Will the employer allow an employee to drop employer health coverage when the employee experiences a reduction of hours (mid-year) and still maintains eligibility in the group health plan

YesNo

May an employee who experiences a mid-year qualifying event be permitted to drop group health plan coverage in order to obtain coverage through the Marketplace

YesNo

When does coverage under the plan terminated for Dependents?The final day of the month of the Dependent’s 26 birthdayThe end of the calendar year of the Dependent’s 26 birthday

There are several plan design options for Health FSAs and Dependent Care FSAs. Clients can choose between two standard Health FSA plan designs and two standard Dependent Care FSA plan designs. In addition, clients with 500 ore more benefit eligible employees can instead choose a custom plan design.

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FSA Plan DesignFSA Plan Types to Implement

Healthcare Reimbursement Account (Health FSA)

Dependent Care Reimbursement Account (Dependent Care FSA)

Effective Date:

End Date:

Are you running a Short Plan Year (SPY)? If yes, maximum election amount should be pro-rated.

No Yes – SPY State Date:

SPY End Date:

Are you aware that employees offered FSA must also be offered group health plan coverage?

Yes No

Eligibility requirements (hours per week):Waiting Period for new employees:When does coverage end after employee termination?:

Are you aware a self-employed individual, partner or person who owns more than 2% of the outstanding stock of the company is not eligible for FSA enrollment?

Yes N

Explanation of Plan Design Option Components:Dependent Care Spend Down:As Dependent Care FSAs are not COBRA eligible, the Dependent Care Spend Down provides a way to avoid terminated participants from forfeiting any balance in their account as of the date of termination. The Spend Down permits the terminated participant to continue to incur expenses through the end of the plan year (and Grace Period if applicable) and submit for reimbursement against the balance in their account as of the date of termination.

Grace Period (Heath FSA and Dependent Care FSA option) Allows participants to continue to incur expenses during the 2 ½ month period following the plan year end date. Does not change run-out date for claims submission.

HEART Act (Health FSA option): Allows members of the US Military Reserves who are called to Active Duty during the FSA Plan Year to be protected from some or all of forfeiture through a Qualified Reservist Distribution (QRD). QRD calculation methods:

Method A: Amount contributed to Health FSA as of Active Duty date minus any reimbursements already received. Method B: Health FSA annual election amount minus reimbursements already received. Method C: Other (amount can’t exceed the annual election minus reimbursements).

Rollover (Health FSA Option) Allows participant balances up to $500 to rollover to the next plan year. If the participant does not elect in the new plan year, an account will open automatically to receive the rollover funds. Maximum Rollover cannot exceed $500. Minimum balance to rollover may be established to avoid paying admin fees on participants with a very small dollar balance who do not elect in the next plan year. The Health FSA cannot have both the Grace Period and the Rollover.

Run-out Period:Number of day after plan year end date in which participants can submit for reimbursement for expenses incurred during the Plan Year (and Grace Period if applicable.) A run-out period can also be established for participants who terminate mid-plan year.

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Health FSA Plan Design Options

Will there be an employer contribution to the Health FSA:

No Yes, $ (match can not exceed $500)

Choose One Health FSA Plan Design. Clients with less than 50 benefit eligible employees should select one of the standard plan design options listed below (HCA Rollover or HCA Grace Period). Clients with 500+ benefit eligible employees may choose a standard plan design option or create a custom plan design.

Standard Plan: HCA Rollover Standard Plan: HCA Grace Period Custom

HCA Rollover HCA Grace Period HCA Custom

Rollover $100 Minimum $500 Maximum

No No Yes*

Minimum:Maximum

Grace Period No Yes Yes* No

Maximum Annual Election

$2,600* $2,600** $2,550

Other:

$

Minimum Annual Election

$100 $100 No Minimum Other:

HEART Act YesQRD Method A

YesQRD Method A

No YesQRD Method:

Run-Out Period after Plan Year Ends

90-days 90-days 90-days

Other:days

Run-Out Period for Participants Terminated From Plan

90-days from termination date

90-days from termination date

90-days from termination date

Other:

days from:

Termination date Plan Year end date

*Cannot have both the Grace Period and the Roll Over** If the federal maximum changes, at the next plan renewal the maximum will be changed to match the new federal maximum

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Dependent Care FSA Plan Design Options

Choose One Dependent Care FSA Plan Design. Clients with less than 50 benefit eligible employees should select one of the standard plan design options listed below (DCA No Grace Period or DCA Grace Period). Clients with 500+ benefit eligible employees may choose a standard plan design option or create a custom plan design.

Standard Plan: DCA No Grace Period Standard Plan: DCA Grace Period DCA Custom

DCA No Grace Period

Standard Plan Grace Period DCA Custom

Grace Period No Yes Yes No

Maximum Annual Election

$5,000* $5,000* $5,000

Other:

$

Minimum Annual Election

$100 $100 No Minimum Other:

Dependent CareSpend Down**

Yes Yes Yes No

Run-Out Period after Plan Year Ends

90-days 90-days 90-days

Other:days

Run-Out Period for Participants Terminated From Plan

90-days from plan year end date

90-days from plan year end date

90-days from termination date

Other: days from: Termination date Plan Year end date

*For standard plans, if the federal maximum changes, at the next plan renewal the maximum will be changed to match the new federal maximum. **If yes this option allows a terminated employee to continue to be reimbursed for eligible dependent care expenses through the end of the plan year.

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Debit Card Requirements Do you want FSA debit cards for participants?

Yes No

Should cards be turned on for both Health FSA and Dependent Care FSA?

Yes No

Will Employer or Employee for the initial set of 2 cards? Employer Employee

If Employer paid, will cards be automatic or optional? Automatic Optional

Will Employer or Employee pay fro additional/replacement sets of 2 cards

Employer Employee

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Initial Debit Card Distribution

The attached example illustrates the Benefit Strategies Flex Express Card. An example is also provided of the card carrier that is included with the cards as well as the envelope in which the set of cards are sent. Debit Cards come in sets of 2 identical cards, both in the name of the participant. An eligible dependent can sign the back of one of the cards for their use. Additional/replacement cards can be ordered. If you select the Grace Period Option for your plan design, cards are left on during the Grace Period and will pull from the prior Plan Year first. When funds are exhausted it will then pull from the current Plan Year.If you elect cards for the Health FSA, cards will be set to work with merchants transmitting a Merchant Category Code (MCC) associated with healthcare (i.e. doctor office, hospital, pharmacy, dental office, vision center, pharmacy.) If you elect cards for a Limited Purpose FSA, cards will be set to work with merchants transmitting a MCC associated with dental and vision care.If you elect cards for a Dependent Care FSA, cards will be set to work with merchants transmitting a MCC associated with childcare facilities, adult day care facilities, etc.

Enrollment information is due to Benefit Strategies, LLC by the below time frame in order to ensure debit cards are mailed prior to the plan start date:January effective dates: No later than December 3rd. All other months: At least 20 days prior to the plan start date.Enrollments received after this date may still have cards mailed prior to the start date but we are not able to guarantee it.

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If you have more than one account type associated to a card (Health FSA and Dependent Care FSA for example), the system determines which account to debit based on the MCC. Participants are required to maintain receipts with their tax records for IRS purposes. Auto-substantiation of debit card transactions reduces the need for participants to send in receipts to substantiate a debit card transaction. Auto-substantiation takes place through the following:IIAS – When a card is used at healthcare merchants (doctors, dentists, pharmacies, etc.) that predominantly sell medical services/products and utilize the Inventory Information Approval System (IIAS), only eligible items will process under the card transaction. For this reason, no documentation is required to be submitted to substantiate the card transaction.

Debit cards are sent to the participants’ home addresses. Send initial cards:

Automatically upon enrollment If employee requests cards at enrollment

*Custom Logo on Debit Card: Yes No (please allow 4 to 6 weeks)

Debits cards are not available for participants on Health FSA COBRA coverage.

Copay Matching Optional Copay Matching – The IRS permits copay matching, up to five times the amount of a copay. This means when a card transaction matches an employer copay amount, or up to five times that amount, no documentation is required to be submitted to substantiate the card transaction.

Implement copay matching (complete and return the attached Copay Matching Template.)

Do not implement copay matching

Debit Card Date of Service

Debit cards should be only used for services and expenses within the current plan year. Paying a medical bill for a service date that was incurred in a previous plan year is considered a non-qualified expense. Debit card claims will be denied for repayment if the date of service is not within the plan year of the account from which funds were drawn.

Debit Card Date of Service during Grace

Debits card transactions made during the Grace Period for services and expenses incurred during the Grace Period will

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Period (if applicable) pull first from the prior plan year; when prior plan year funds are exhausted, the card will pull from the current plan year funds. Debit card transactions made during the Grace Period for services and expenses incurred in the prior plan year will be denied and repayment requested if there are insufficient funds available from the prior plan year to cover the full amount of the debit card transaction.

Debit Card Substantiation Notifications

Two notifications are sent via email (if email is not provided a letter will be mailed to address on file) to request that participants provide substantiation for debit card claims that are not auto substantiated. Notifications are sent at 7 days and 37 days from the date of the debit card transaction.

Transaction Dispute Process

If a participant believes their account has been charged in error, the participant should call the phone number on the back of their debit card as soon as possible. If appropriate, an Activity Dispute form will be provided to the participant. This form must be completed and submitted as soon as a disputed transaction is identified. Note: Activity Dispute forms must be received within 90 calendar days from original transaction(s) settlement date.

Employer Reports

Account Balance Report Sample

Enrollment Report Sample

Payroll Deduction Report Sample

Reports are scheduled to run on a monthly basis.Reports are posted on the Employer Portal for access by Employer Portal users with reporting permission. Reports will be provided in an MS Excel format when this option is available, but a PDF may be requested instead if this format is required.

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Employer Portal Users and Access LevelsEnter information below for each Employer Portal user and the level of access required. An email will be sent to each contact with information regarding use of the Employer Portal and log in credentials.

Employer Portal UserName: Title: Email: Phone Number: Access Level

Employer Portal UserName: Title: Email: Phone Number: Access Level:

Employer Portal UserName: Title: Email: Phone Number: Access Level

Employer Portal UserName: Title: Email: Phone Number: Access Level:

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Participant FormsSpending Account Self Service Forms – all forms are located on www.benstrat.com under the FSA tab as well as within the employer and employee portals.Claim Reimbursement Form

Used to file Health and Dependent Care Account Claims if faxed or mailed instead of being entered directly in the Consumer Portal or through the mobile app.

Direct Deposit Authorization Form

Used if direct deposit account information is faxed or mailed instead of being entered directly in the Consumer Portal.

Health Care Eligible and Ineligible FSA Expenses

List of Health Care Expenses based on a list of eligible and ineligible expenses as provided for under IRS Publication 502.

Physician Statement To be used for “dual use” services: Any service not typically considered eligible but recommended by a physician on a case by case basis to cure, alleviate or mitigate a medical condition or to treat an existing disease. Example: massage therapy to treat migraines.Note: This is not to be used for over-the-counter (OTC) medications and drugs. A prescription is required for those items to be eligible.

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Participant EducationParticipant Account Demo – Introduction to Flexible Spending Account:

Participant Account Demonstration:

Participant Online Enrollment Demonstration:

Participant Communications

FSA participants include employees, COBRA participants, or terminated employees still within their run out and/or grace period and require the ability to file claims against their spending account balances. Email notifications are sent to active participants with an email address when the letters below are generated. The email notification informs the participant the associated letter is available for viewing via the Consumer Portal.

Spending Account Self Service NotificationsNotice Type Email Sample

Claim Denial Emailed Notification

Claim Denial with Repayment Required

Advice of Deposit for Claim Reimbursement

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Fees

Set Up Fee: $ Invoiced To:

Renewal Fee: $ Invoiced To:

Plan Takeover Fee: $ Invoiced To:Monthly Admin Fee and Minimum Monthly Invoiced Amount : $ Invoiced To:

Initial Card Fees $Replacement/Additional Card Fees: $

Invoiced To: Invoiced To:

Non-Discrimination Testing Per Plan Per Test (done upon request) :$ Invoiced To:

Acceptance

We have reviewed and approved the contents of the Flexible Spending Account Administration Guide and Requirements Gathering Document (dated). We certify that the content included is in a manner that accurately reflects the Flexible Spending Account Requirements for (client name). By signing this document we understand Benefit Strategies, LLC will begin administering Flexible Spending Accounts based on the information detailed in this document.

Any changes made to the plan design after implementation is complete will be deemed a plan change. Plan changes made off of renewal may be subject to a plan re-build fee.

Authorization

Authorized Signature Title

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Printed Name Date

Thank you for partnering with Benefit Strategies; we look forward to working with you and your employees!

Please sign this form and return it via email to implementation@benstrat.com

Benefit Strategies, LLC

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