Get Payflex Pf-111-1 2019-2025

This guide provides a comprehensive overview of how to effectively complete the PayFlex PF-111-1 Reimbursement Accounts Enrollment Form online. By following these clear steps, users can ensure they provide all necessary information accurately and efficiently.

Follow the steps to complete the PayFlex PF-111-1 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor for completion.
2. Begin by filling out the 'Employer Use Only' section, including the employer ID number, selection of re-enrollment, new, or change, and effective dates.
3. In section A, provide your personal information. Ensure you print clearly as you enter your employer name, first name, middle initial, last name, social security number, street address, city, state, ZIP code, email address, date of birth, and date of hire.
4. Move to section B for Election Information. Indicate your choice to enroll or not by checking the appropriate box. If you choose to participate, specify your desired contribution amounts for the Health Care FSA, Limited Purpose FSA, and Dependent Care FSA, as applicable.
5. In the payment sections, enter the per pay period amount and the number of pay periods to calculate the total Plan year amount for each benefit choice.
6. Review the statements provided at the bottom of the form. By signing, you confirm your understanding of the enrollment terms and conditions. Make sure to read each statement carefully before signing.
7. If you wish to participate in direct deposit, complete section C by authorizing PayFlex to initiate credit entries to your account. Remember to include a 'VOIDED' check or savings deposit slip.
8. After filling out all necessary sections, review the form for accuracy and completeness. Finally, save your changes, download, print, or share the form as needed.

Complete your PayFlex PF-111-1 form online today for a smooth enrollment experience.