2024 GB-02 Flexible Spending Arrangement Enrollment Form

The plan member must complete this form each year during annual enrollment to enroll into a Flexible Spending Arrangement (FSA). New hires have 30-days in which to decide to enroll in a FSA and complete this form.

2025 GB-02 Flexible Spending Arrangement Enrollment\Stop Form

New employees wishing to enroll in a Flexible Spending Arrangement complete this form and return to their HR department within 30 days of their hire date. This form can also be used for an enrollee experiencing a qualifying event and needs to make a change to his/her coverage or enrolling in an FSA during the annual enrollment period.