FSA Enrollment Form

FSA Enrollment Form — Form Fields

This hr template includes 9 fields. Enroll in the company Flexible Spending Account program for healthcare or dependent care expenses. Free to customize and use on ZenBuild.

• Employee Name (text, required)
• Work Email (email, required)
• Employee ID (text, required)
• FSA Type (dropdown selection, required) — options: Healthcare FSA, Dependent Care FSA, Both
• Annual Healthcare FSA Contribution ($) (number, optional)
• Annual Dependent Care FSA Contribution ($) (number, optional)
• Enrollment Period (dropdown selection, required) — options: Open Enrollment, New Hire, Qualifying Life Event
• Qualifying Life Event (if applicable) (text, optional)
• Have you read the FSA plan summary? (multiple choice, required) — options: Yes, No