Burnham & Flower Group Flexible Spending Account Enrollment Form

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

  • 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
  • This is normally your date of hire or event change date.
  • Employee Name * Required
  • Address * Required
  • Email * Required
  • Payroll Frequency * Required
  • The maximum total contribution for 2020 is $2700.00. 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 for 2020.
  • The maximum total contribution for 2020 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 for 2020.
  • Spouse/Partner's Name
  • Dependent #1 Name
  • Dependent #2 Name
  • Dependent #3 Name
  • Do you have more than three(3) dependent children?
    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.

If you need further assistance please email Jenn Williams or contact Jenn on Microsoft Teams.