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Employees Retirement System of Texas (ERS) TexFlex Enrollment/Change Form
 

Summary: Employees Retirement System of Texas (ERS)
TexFlex Enrollment/Change Form
Employee name: SSN: ERS OnLine EmplID:
Only for participants with active employee benefits.
1. I have experienced a qualifying life event (QLE) of ________________________________________ that allows me to
enroll in or change my Flex Spending account. The event date of this QLE is:______________ (MM/DD/YYYY)
Flex Spending Health for eligible medical and dental out of pocket costs excluding insurance premiums, which has a
minimum annual pledge of $180 and a maximum annual pledge of $5000 per tax year. Enrollment/change must be made within 31
days of my employment or qualifying life event. If you do not check this box, you will not be enrolled in this account.
Flex Spending Dependent Day Care for eligible child or adult dependent day care expenses, which has a minimum annual
pledge of $180 and a maximum annual pledge of either $5000 or the lesser of my or my spouse's annual income that is below $
whichever is lower. Enrollment/change must be made within 31 days of my employment or qualifying life event.
5000,
2. *The Flex-Health and Flex-Day Care accounts each have an annual administrative fee. The fee will be automatically deducted from your
account(s) and will be in addition to the annual debit card fee should you elect to use the debit card.
3. I would like to use the PayFlexSM
Debit Card for an annual fee of $15 (pro-rated for new participants), which is
deducted from my Flex Spending account automatically during my first month of enrollment.
Yes (If you already have a card, continue to use that card; otherwise, one will be mailed to you.) No
Section A: (always complete)

  

Source: Azevedo, Ricardo - Department of Biology and Biochemistry, University of Houston

 

Collections: Biology and Medicine; Environmental Sciences and Ecology