[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-301940-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-301940-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","sisc-flex-plan-enrollment-form-employer-code-plan-year-benefits-elections","SISC Flex Plan - Enrollment Form - Employer Code, Plan Year, Benefits Elections","","Enrollment form for the SISC Flex Plan collects employer details (employer code, plan year dates, submission deadlines) and employee personal information, then supports Benefit Elections for Section 125 accounts: Health Care Expense Account, Limited Purpose Health Care Expense Account, and Dependent Care Expense Account. It also captures Debit Card and Direct Deposit options and requires employee and employer signatures. Additional guidance covers reimbursement eligibility, premium restrictions, prorating, Use-it or Lose-it, and grace-period rules.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/sisc-flex-plan-enrollment-form-employer-code-plan-year-benefits-elections/301940/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/sisc-flex-plan-enrollment-form-employer-code-plan-year-benefits-elections/301940.png","ImageObject",442,249,{"name":42,"@type":43},"Mason","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-23","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":30},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What benefit accounts can employees elect on this form?","Question",{"text":62,"@type":63},"Employees can elect a Health Care Expense Account, a Limited Purpose Health Care Expense Account, and a Dependent Care Expense Account (with Yes/No election and annual election amounts).","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"When is the deadline to submit claims and what is the grace period?",{"text":67,"@type":63},"The last day to submit claims is 3/31/2027, and the grace period runs through 3/15/2027 for incurring expenses against the prior plan year.",{"name":69,"@type":60,"acceptedAnswer":70},"What rules apply to unused funds and debit card usage?",{"text":71,"@type":63},"Unused funds after the run-out period cannot be refunded (Use-it or Lose-it). Debit cards are available at no cost for a 3-year validity period and require providing a valid e-mail address to use the card.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},301940,1790056168,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":30,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":139,"read_time":22},5909887256941,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","SISC Flex Plan – Enrollment Form Employer Code: SIS  \nPlan Year: 1/1/2026-12/31/2026 with Grace Period through 3/15/2027  \nLast Day to Submit Claims: 3/31/2027  \n| Employer | Effective Date |\n| --- | --- |\n|  |  |\n\nEmployee Information – Please write legibly to ensure proper enrollment  \n\n| First Name Last Name |  |  | SSN |\n| --- | --- | --- | --- |\n|  |  |  |  |\n| Home Address (Street, City, State, Zip Code) |  |  | Date of Hire |\n|  |  |  |  |\n| Date of Birth | Phone Number | E-mail Address (Mandatory for Debit Card) |  |\n|  |  |  |  |\n\nBenefit Elections  \n\n| Section 125 Benefit | Yes/No | Annual Election | \\# of Deductions | Paycheck Deduction |\n| --- | --- | --- | --- | --- |\n| Health Care Expense Account\u003Cbr>Maximum of $3,300.00 per plan year | ❑ Yes\u003Cbr>❑ No | $  | _______ | $  |\n| Limited Purpose Health Care Expense Account\u003Cbr>Maximum of $3,300.00 per plan year\u003Cbr>This account is for employees enrolled in a High Deductible Medical Plan and enrolled in a Health Savings Account (HSA). | ❑ Yes\u003Cbr>❑ No | $  | _______ | $  |\n| Dependent Care Expense Account\u003Cbr>(Daycare or Eldercare)\u003Cbr>Maximum of $7,500.00 per plan year\u003Cbr>(or $3,750.00 if you’re married and filing taxes separately) | ❑ Yes\u003Cbr>❑ No | $  | _______ | $  |\n\nList any month(s) payroll deductions will not be taken for account(s) listed above.   Debit Card & Direct Deposit  \n\n| Navia Debit Card – You may use the card to pay for expenses directly from the funds in your Health Care, Limited Purpose and Dependent Care Expense Account. There is no cost for debit cards. Cards are valid for a 3 year period; if you’ve previously received a card then it will be reloaded with your new election. You must provide a valid e-mail address to use the card. |  |  |  |  | Automatic |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Direct Deposit – Reimbursements are electronically deposited into your bank account. If you’ve previously signed up for direct deposit with Navia your information will remain on file and you do not need to complete this section. |  | ❑ Checking\u003Cbr>❑ Savings | Routing \\#: |  |  |  |\n|  |  |  | Account \\#: |  |  |  |\n\nSignature  \n\n| This election form will remain in effect and cannot be revoked or changed during the plan year unless the revocation and new election are on account of and consistent with federal regulations. I understand that Health or Limited Purpose Expense Account reimbursements will be available only for qualifying medical care expenses for myself, spouse, and dependents. I also understand that Dependent Care reimbursements will be available only for qualifying day care and adult care expenses. I agree to notify the Plan Administrator if I have reason to believe that any expense for which I have obtained reimbursement is not a qualifying expense. I also agree to indemnify and reimburse the Plan Administrator or Employer on demand for any liability it may incur for failure to withhold federal, state or local income tax or Social Security tax from any reimbursement I receive of a non-qualifying expense, up to the amount of additional tax actually owed by me. I understand the benefits and I have read the reverse page. I hereby authorize and direct my employer to reduce my salary by the amount necessary to pay for the benefit(s) as shown above for the plan year indicated above. |  |\n| --- | --- |\n| Employee Signature | Date |\n| X |  |\n| Employer Signature | Date |\n| X |  |\n\nCompleted Enrollment Forms must be returned to Employer  \nPlease see the reverse side for important information regarding the above benefits  \nAdditional Information   \nHealth Care Expense Account  \n▪ Reimbursement will only be available for qualifying medical care expenses as set forth in the Plan Document, Eligible Expense List, and Section 213 of the Internal Revenue Code. It is your responsibility to check the eligibility of an expense prior to enrollment.  \n▪ Group Medical Plan Premiums cannot be reimbursed through the Health Care Expense Account and may be deducted pr","cbCaijNjCOWQR69d","https://ap.wps.com/l/cbCaijNjCOWQR69d","pdf",86009,"English","# Employer and Plan Details\n## Employee Information\n## Benefit Elections\n## Debit Card & Direct Deposit\n## Signature\n# Additional Information\n## Reimbursement and Eligibility Rules\n## Use-it or Lose-it and Grace Period","[{\"question\":\"What benefit accounts can employees elect on this form?\",\"answer\":\"Employees can elect a Health Care Expense Account, a Limited Purpose Health Care Expense Account, and a Dependent Care Expense Account (with Yes/No election and annual election amounts).\"},{\"question\":\"When is the deadline to submit claims and what is the grace period?\",\"answer\":\"The last day to submit claims is 3/31/2027, and the grace period runs through 3/15/2027 for incurring expenses against the prior plan year.\"},{\"question\":\"What rules apply to unused funds and debit card usage?\",\"answer\":\"Unused funds after the run-out period cannot be refunded (Use-it or Lose-it). Debit cards are available at no cost for a 3-year validity period and require providing a valid e-mail address to use the card.\"}]","SISC Flex Plan - Enrollment Form - Employer Code, Plan Year, Benefits Elections | PDF",1789787017]