Wimberly
Associates, Inc.
ON LINE
Election Form and Compensation Agreement For The 2012 Calendar Plan
Year
Please complete the form, read and accept the
provisions, and click on enroll.
Personal
Information
Your Address for Mailing:
IMPORTANT FOR ON-LINE ACCESS!!!!!
IMPORTANT FOR ON-LINE ACCESS!!!!!
ELECTION TO PARTICIPATE IN THE MEDICAL FSA
I elect to receive medical reimbursements for
qualifying medical care expenses that are incurred during the Plan
Year in lieu of taxable compensation. I further understand that I must
submit proof of actual expense in order to receive reimbursement.
(Please not that the rules for receiving reimbursement for Over The
Counter medications have been changed by the recent Healthcare Reform
Act.) I understand that I will have until March 15th, 2013 to incur
these expenses and that I may be subject to forfeiture if I don't
incur and request reimbursement within the alloted timeframes. The
annual amount of my election is:
I waive
this coverage
ELECTION TO PARTICIPATE IN THE DEPENDENT CARE FSA
I elect to receive dependent care assistance in lieu
of taxable compensation. I understand that I may receive
reimbursements only for qualifying dependent care as defined by the
IRS on their form 2441. I further understand that at the administrator
requires a completed form W-10 and that I must submit proof of actual
expense in order to receive reimbursement. I also understand that my
federal dependent care credit is reduced dollar for dollar by any
amounts received by me under this plan.
I elect this coverage. The
annual amount of my election is:
I waive
this coverage
ELECTION TO PARTICIPATE IN THE PARKING ACCOUNT (Not Available in All Plans)
I elect to reduce my wages in order to receive reimbursements under
my employers Parking Account. Maximum per month in 2012 is $230. I understand that my expenses must be incurred during the Plan
Year and that my reimbursements can never exceed my year to date
contributions.
I elect this coverage. The
annual amount of my election is:
I waive
this coverage
ELECTION TO PARTICIPATE IN THE TRANSIT ACCOUNT (Not Available in All Plans)
I elect to reduce my wages in order to receive reimbursements under
my employers Transit Account. I understand that I may receive
reimbursements only for qualified Transit expenses. Maximum amount in
2012 is $230. I understand that my expenses must be incurred during the Plan
Year and that my reimbursements can never exceed my year to date
contributions.
I elect this coverage. The
annual amount of my election is:
I waive
this coverage
ELECTION TO PARTICIPATE IN THE OTHER QUALIFIED
INSURANCE ACCOUNT (Not Available in All Plans)
I elect to reduce my wages in order to receive
reimbursements under my employers Other Qualified Insurance Premiums
plan. I understand that I may receive reimbursements only for
qualified accident and health insurance, as defined by Section 105 and
106 of the Internal Revenue Code and further listed in IRS Publication
502. I understand that my expenses must be incurred during the Plan
Year and that my reimbursements can never exceed my year to date
contributions.
I elect this coverage. The
annual amount of my election is:
I
waive this coverage
OTHER TERMS AND CONDITIONS
By participating in my employer's Section 125 Plan,
I understand the following conditions:
I cannot change or revoke this agreement during the Plan Year without
prior approval of the Plan Administrator and unless I have a qualified
change of family status (death, divorce, disability, marriage, birth
of child, loss of employment, change in spouse's employment.)
The Plan Administrator may cancel or modify my election in the event
he believes it is advisable in order to satisfy certain provisions of
the Internal Revenue Code.
To receive reimbursements, I will be required to
complete a standard claim form and provide third party documentation
to the Plan Administrator.
Amounts left unclaimed in my account after May 15, 2013 will be forfeited by me in accordance with
the Plan SPD and current IRS
requirements.
My social security benefits may be slightly reduced due to reduced
contributions on my part.
This agreement is subject to the terms and provisions of the Plan
Document, which I may review in accordance with current IRS
requirements.
By entering my date of birth and transmitting
this form, I agree to be bound by all the terms of this agreement
between myself and my employer.