November 8, 2018
Caroline Esmurdoc
Double Fine Productions, Inc.
525 Brannan St
#200
San Francisco, CA 94111
RE: Flexible Spending Account Client Kit
Client Code: L06321
Dear Caroline:
Welcome and thank you for selecting Ceridian to administer your Flexible Spending Account (FSA) for the 2009 plan year. Enclosed are materials to help you with the ongoing administration of your FSA.
Participation Report (separate attachment)
This report is a post-enrollment summary of your participants' selections.Please review it for accuracy.
Administrative forms
To assist you in getting started for the new plan year, included are the following forms:
- Change Request form
- Leave of Absence form
- Termination form
Giving timely and accurate employee change information can greatly reduce overpayment risk. Overpayments can negatively affect both you and your participants. The enclosed forms are one way to minimize this exposure.
We look forward to working with you in the 2009 plan year! Please don't hesitate to call 800-488-8757 or email should you have any questions.
Sincerely,
Client Service Support
Phone: (800) 488-8757
Fax: (727) 395-1862
Email:
Enclosures
Flexible Spending Account (FSA)
Election Change Request Form
Employee Name:
SSN:
Step1: Check the box that indicates which event qualifies for a change in your FSA election.
The event must affect your eligibility for FSA coverage to be considered.
Change in legal marital statusincluding marriage, death of spouse, divorce, legal separation and annulment.
Change in the number of dependents including birth, death, adoption, and placement for adoption.
Change in employment status that affects eligibility for benefits of the employee, the employee’s spouse, or the employee’s dependent including commencement of employment, termination of employment, commencement of or return from an unpaid leave of absence, full-time to part-time, part-time to full-time.
Change in dependent’s eligibility under an employer’s plan such as attainment of age, student status, or similar circumstances.
Change in Dependent Care costs or provider.
Judgment, Decree or Order affecting payment of benefits.
COBRA Qualifying Event with respect to the employee, the employee’s spouse or employee’s dependent and affecting coverage under the group health plan of the employee’s employer.
Entitlement to Medicare coverage.
Step 2:Indicate how you wish to change your FSA election(s).
You may not decrease an election below what you have been reimbursed from or contributed to that account. The election change will be effective for expenses incurred during the remainder of the plan year. Your initial annual election will continue to apply to expenses incurred prior to the effective date of this election change.
Health
FSA / Increase my election to$ .00 /
Decrease my election to
$ .00 / Revoke my electionYTD Deduction ______
Dependent
Care FSA / Increase my election to
$ .00 /
Decrease my election to
$ .00 / Revoke myelectionYTD Deduction ______
Step 3:Sign below to indicate your approval of the following statement:
If approved, I hereby elect the changes indicated above to my FSA election(s) and attest that any changes requested are on account of and consistent with the change in election event.I understand I may be required to provide appropriate documentation and that this change in election request has the same effect as my initial annual election.
Employee SignatureDate
For Plan Administrator Use
Client: Double Fine Productions, Inc. (C) / Client Code: L06321Authorized Signature: / Name:
Election change effective date: / Payroll period effective date:
Flexible Spending Account (FSA)
Unpaid Leave of Absence (LOA) Form
Employee Name:
SSN:
Your employer's plan permits a Health Flexible Spending Account (HFSA) participant the following options while on an unpaid leave of absence, under Internal Revenue Service regulations. Choose one of the following options prior to beginning your LOA. You may not change the underlying HFSA election amounton account of commencing or returning from the LOA; this form addresses whether you want HFSA coverage and how you will pay for it.
Revoke – By choosing this option, I elect to revoke contributions to my HFSA during my LOA. I understand my period of coverage will end as of the first day of my LOA and that claims incurred after this date will not be eligible. I also understand that when I return to work, I may re-enter the plan with the same deductions elected before my LOA and that I must contact my plan administrator if I wish to do so.
Prepay – By choosing this option, I elect to prepay my HFSA contributions for the full period of my LOA. If the LOA extends into the next plan year, I understand that prepayment is not an option for the period that extends into a subsequent plan year. I understand that one (pretax) deduction will be taken from the final paycheck before my LOA begins to cover the entire amount of deductions (within the current plan year) that would have been made during the LOA. I further understand my period of coverage will extend throughout the LOA and claims for expenses incurred during my LOA period will be eligible for reimbursement. My contributions to the HFSA will resume upon my return from LOA.
Pay-as-you-go – By choosing this option, I elect to make contributions to my HFSA on an aftertax basis under the same schedule of payments as when I am not on a LOA. I understand that my period of coverage will extend throughout the LOA and claims for expenses incurred during my LOA will be eligible for reimbursement.
Catch-Up – By choosing this option, I understand that during my LOA, my employer has agreed to make contributions to my HFSA. I further understand that when I return to work, the amount of contributions my employer made on my behalf will be deducted from my paychecks on a pretax basis.
I consider this amount a debt I owe my employer. I understand that my period of coverage will extend throughout the LOA and claims for expenses incurred during my LOA will be eligible for reimbursement.
If this form is not submitted before a LOA begins, participation in the HFSA will be revoked during the entire period of LOA and the HFSA will be subject to the provisions of a revoked account, as outlined above.
Employee Signature: ______Date: ______
For Plan Administrator Use
Client: Double Fine Productions, Inc. (C) / Client Code: L06321Authorized Signature: / Name:
LOA effective date: / Payroll period effective date:
Flexible Spending Account (FSA)
Termination of Coverage and
Health FSA COBRA Continuation Form
STEP 1: Notify Ceridian of termination of FSA coverage
Notify Ceridian when an employee terminates employment in order for the FSA account to be updated correctly. Please include all the requested data to ensure accurate processing of the termination.
Reminder: Delayed notification could result in overpayment to employee.
Name / SSN / Term Date / Date of Last Deduction / Year to date Deductions Health FSA / Year to date Deductions Dependent Care FSA- -
- -
- -
- -
- -
STEP 2: Determine COBRA eligibility for the Health FSA
Most Health FSA plans are generally subjected to COBRA continuation rules, including initial notice and elections after a qualifying event. Your FSA Administration Manual contains materials to assist you in determining whether and to be what to extent you may be required to provide continuation for the Health FSA. Your Account Manager is available to answer any additional questions.
STEP 3: Notify Ceridian when employee elects COBRA Continuation
This section applies only to a Health FSA. In order to accurately process COBRA continuation coverage, each month you must notify Ceridian that the participant has elected coverage and the date through which Health FSA continuation coverage has been paid.
Name / SS# / Term Date / COBRA Premium Paid Thru Date- -
- -
- -
For Plan Administrator Use
Client: Double Fine Productions, Inc. (C) / Client Code: L06321Authorized Signature: / Name: