FLEXIB
BLE SPEN
NDING AC
CCOUNT
C
CONSENT TO ALLO
OW
THE $
$500 ROL
LLOVER O
OPTION
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Group Informattion
Gro
oup Name:_
___________
__________
_______ SelectAccoun
nt Group Nu
umber: ____
___________
________
Plan Yea
ar Informa
ation
Am
mend the currrent FSA plan
p
effectiv
ve:
2013 plan year
y
to roll into 2014 plan year
Does your 2013
2
FSA cu
urrently have
e a grace pe
eriod?
Yes – amend my
y plan docum
ments to rem
move the gra
ace period
No
y
to roll into 2015 plan year
2014 plan year
Does your 2014
2
FSA cu
urrently have
e a grace pe
eriod?
Yes – amend my
y plan docum
ments to rem
move the gra
ace period
No
Siignature
I ha
ave reviewed
d the above amendmentts and underrstand these
e changes w
will remain in effect for the entire
plan
n year.
___
___________
__________
__________
________
Signature of Group
G
Leade
er
________
__________
_______
Date
If yo
ou have any
y questions, please call our
o Group Le
eader Line a
at 1-888-460
0-4013. Whe
en complete,, either fax
this form to 651-662-7247 or
o email it to SelectAcco
ount_Group_
_Administrattion@selecta
account.com
m.
MII Life
e, Inc. d.b.a. SelectAccount
S
/ P.O. Box 64
4193, St. Paul,, MN 55165-0193 / www.selectaccount.co
om
(651
1) 662-5065 or (800) 859 -2 144
X200
070R02 (11/13
3)