Section 125 Pre-Tax Enrollment Form
Employee Information
Employee Name
Employee ID
Department
Date of Birth
Social Security Number
Address
Phone Number
Email
Enrollment Election
Enroll
Waive
Change
Benefit Selections
Health Insurance
Single
Employee + Spouse
Employee + Children
Family
Dental Insurance
Single
Family
Vision Insurance
Single
Family
Flexible Spending Account (FSA) Annual Amount
Dependent Care FSA Annual Amount
Dependent Information
Name
DOB
Relationship
Authorization & Signature
I authorize my employer to reduce my salary by the amount necessary for the benefits I have selected.
Employee Signature
Date