This form will allow us to amend your company's Health FSA plan in accordance with new IRS guidance related to COVID-19.

First Name *

Last Name *

Company Name *

Email *

Phone Number *

Plan/Program Name *

i.e. “ABC Company FSA Plan”

Do you wish to amend your FSA Plan to allow mid-year election changes. *

• Yes, I understand I will be charged $200.
• No, I only elect to make the required amendment. Please submit this form now. You will not be charged for this amendment.
• Please contact me to discuss our options.

If yes, please amend our Health FSA plan to allow participants to do the following:

• Make a new election, even if the employee had previously declined
• Increase, decrease, make a new election or revoke an existing election for a health FSA

Please choose all that apply.

For the Premium Only portion: please amend to allow participants to do the following:

• Revoke an existing election and make a new election of different health coverage offered by the employer.
• Revoke an existing election and make a new election in a plan not offered by the employer.

Please choose all that apply

If your plan currently allows a 2.5 month Extended Grace Period:

• Please amend the plan to extend the Grace Period until December 31, 2020
• Please keep our Extended Grace Period as it currently exists.

Choose one.

If your plan currently allows a $500 Carryover Provision:

• Please amend the plan to raise the $500 Carryover to $550.
• Please keep the amount of our Carryover as is.

Please choose one.

If your plan currently does not allow for an Extended Grace Period or Carryover:

• Please amend our plan to include an Extended Grace Period.
• Please amend our plan to include a $550 Carryover Provision
• Please keep our plan as it currently exists.

Please choose one.

Please share any additional information.

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