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Benefits Enrollment · Pro

Streamline Employee FSA & Benefits Enrollment Today

Simplify FSA elections and supplemental benefits enrollment with a structured form that guides employees through healthcare, dependent care, and voluntary benefit options.

Use This Template Free Preview

Obsidian theme

formbuilder.ai/f/employee-flexible-spending-account-supplemental-benefits-enrollment-form

Employee Flexible Spending Account & Supplemental Benefits Enrollment Form

Employee Full Name

· · ·

Work Email Address

· · ·

Phone Number

· · ·

Submit

The Employee Flexible Spending Account & Supplemental Benefits Enrollment Form helps HR teams efficiently collect and manage employee benefit elections during open enrollment periods or qualifying life events. It covers Healthcare FSA, Dependent Care FSA, and Limited Purpose FSA elections alongside voluntary supplemental benefits, ensuring accurate payroll deductions and IRS compliance.

This form is ideal for HR departments, benefits administrators, and payroll teams at organizations of any size. By centralizing FSA and supplemental benefit elections in one place, it reduces administrative errors, saves time, and provides employees with a clear, guided enrollment experience complete with IRS contribution limit reminders.

With customizable fields for employee information, annual election amounts, and supplemental benefit selections, this template adapts to your organization's specific benefit offerings. Pre-tax and post-tax deduction options are clearly communicated, helping employees make informed decisions while keeping your HR records organized and audit-ready.

4 Pages

26 Questions

~9min To complete

Free No credit card needed

Field types Short Text ×5 Dropdown ×3 Yes / No ×3 currency ×3 Date ×2 Single Choice ×2 Full Name Email Phone Multiple Choice Long Text number termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Employee Information 8 questions

Employee Information

1 Employee Full Name * Full Name

2 Work Email Address * Email

3 Phone Number * Phone

4 Employee ID Number * Short Text

5 Department * Short Text

6 Job Title * Short Text

7 Date of Hire * Date

8 Employment Status * Dropdown

Page 2 Flexible Spending Account Elections 6 questions

Flexible Spending Account (FSA) Elections

Select the FSA accounts you wish to enroll in for the current plan year. Please review IRS contribution limits before making your elections. Changes can only be made during open enrollment or following a qualifying life event.

1 Do you wish to enroll in a Healthcare Flexible Spending Account (HCFSA)? * Yes / No

2 Healthcare FSA Annual Election Amount currency

3 Do you wish to enroll in a Dependent Care Flexible Spending Account (DCFSA)? * Yes / No

4 Dependent Care FSA Annual Election Amount currency

5 Do you wish to enroll in a Limited Purpose FSA (Dental/Vision only)? * Yes / No

6 Limited Purpose FSA Annual Election Amount currency

Page 3 Supplemental Benefits Enrollment 5 questions

Supplemental Benefits Enrollment

Select any additional voluntary benefits you would like to enroll in. Premium costs will be deducted from your paycheck on a pre-tax or post-tax basis depending on the benefit.

1 Supplemental Benefits Elections (select all that apply) * Multiple Choice

2 Supplemental Life Insurance Coverage Level Dropdown

3 Do you wish to add spouse/domestic partner coverage for supplemental benefits? * Single Choice

4 Do you wish to add dependent child(ren) coverage for supplemental benefits? * Single Choice

5 List covered dependents (Full Name, Date of Birth, Relationship) if applicable Long Text

Page 4 Beneficiary Designation & Authorization 7 questions

Beneficiary Designation

1 Primary Beneficiary Full Name * Short Text

2 Primary Beneficiary Relationship * Dropdown

3 Primary Beneficiary Percentage (%) * number

4 Contingent Beneficiary Full Name Short Text

Authorization & Signature

By signing below, I authorize the deduction of elected FSA contributions and supplemental benefit premiums from my paycheck. I understand that FSA elections are irrevocable during the plan year unless I experience a qualifying life event. I certify that all information provided is accurate and complete.

5 I have read and agree to the enrollment terms, payroll deduction authorization, and plan documents. * termsandconditions

6 Date of Enrollment * Date

7 Employee Signature * Signature

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.