Burnham & Flower Group Flexible Spending Account Enrollment Form – Human Resources

Please complete the form below to enroll in Burnham & Flower Group Flexible Spending Accounts. Enrollment or changes must be made within 30 days of qualifying event date to be eligible for Special Enrollment.

BFG FSA Enrollment Form

Employer * Required
Employer ID * Required
Employee ID Number * Required
This can be found on your K ID card. It should have leading zeros in front of it to make it a 7-digit number. Example: 0123456
Benefit Effective Date * Required
Month
Day
Year

This is normally your date of hire or event change date.
Employee Name * Required
First Last
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone * Required
Email * Required
Enter Email Confirm Email
Date of Birth * Required
Month
Day
Year
Payroll Frequency * Required
- BiWeekly
- Monthly
Health Care Flexible Spending Account Contribution Per Pay Period

The maximum total contribution for 2023 is $3050.00. The max for 2024 is $3200. Please multiply your contribution by the number of biweekly or monthly payrolls remaining for the calendar year to make sure you are within the IRS limits.
Dependent Care Flexible Spending Account Contribution Per Pay Period

The maximum total contribution for 2023 and 2024 is $5,000.00. Please multiply your contribution by the number of biweekly or monthly payrolls remaining for the calendar year to make sure you are with in the IRS limits.
Spouse/Partner's Name
First Last
Spouse/Partner's Date of Birth
Month
Day
Year
Dependent #1 Name
First Last
Dependent #1 Date of Birth
Month
Day
Year
Dependent #2 Name
First Last
Dependent #2 Date of Birth
Month
Day
Year
Dependent #3 Name
First Last
Dependent #3 Date of Birth
Month
Day
Year
Do you have more than three(3) dependent children?
- Yes
- No
- N/A
Please click here if you have more than 3 dependent children so a member of Human Resources may reach out to you for further enrollment information.
Payroll Deduction Authorization * Required

I understand that the reduction(s) specified above will be in effect for such a Plan Year and can be revoked or
changed only if the election change is due and consistent with a change in status as defined in Section 125 of the
Internal Revenue Code. I further understand that any salary reduction amounts not used by the end of the above plan
year for eligible expenses incurred during the plan year would relate to the new medical FSA carryover rule. In late
2013, the IRS modified the “use-it-or-lose-it” forfeiture rule for medical FSAs and your employer amended the plan
to permit a $600 annual carryover (for 2023 and $640 for 2024) of an employee’s unused account balance. I hereby authorize my employer to
reduce my salary each pay period on a pre-tax basis by the amount of my benefit election(s) specified above.
Signature * Required
Date * Required

If you need further assistance please email Human Resources.