Get Enrollment Form - Fsa Dca Pop.indd - Polestar Benefits

This guide provides clear instructions on how to effectively complete the Enrollment Form - FSA DCA POP.indd for Polestar Benefits. Follow these steps to ensure that your information is accurately submitted and processed.

Follow the steps to fill out your enrollment form online.

1. Click the ‘Get Form’ button to access the Enrollment Form - FSA DCA POP.indd and open it in your preferred editor.
2. Fill in the employer details in the designated section, including the employer's name and the effective date of benefits.
3. Indicate your enrollment type by selecting either 'Open Enrollment/New Hire' or 'Add/Change' and specify the reason if applicable.
4. Complete the employee information section by providing your last name, first name, mailing address, city, state, zip code, social security number, date of hire, date of birth, gender, email address, phone number, and alternate phone number.
5. If applicable, provide dependent information by entering the names, dates of birth, and enrollment decisions (enroll or waive) for each child and spouse.
6. In the section for the Flexible Spending Account, input your elected pay period amounts and the total annual election for both the flexible spending and dependent care accounts.
7. Fill out the monthly election total for the Premium Only Plan.
8. Read and acknowledge the declarations regarding deductions, claims, and participation in the programs provided by your employer.
9. Provide your signature and the date to confirm all statements and information provided are accurate.
10. If choosing not to participate, complete the declination section by indicating your choice for each account, sign, and date it.
11. If opting for direct deposit, provide the required bank information including account type, routing number, and account number, and sign where indicated.
12. Review the completed form to ensure all necessary fields are filled accurately. Save your changes, and utilize the options to download, print, or share your completed form.

Complete your Enrollment Form - FSA DCA POP.indd online today to secure your benefits.