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Odessa R-VII School District 2017
Flexible Spending Account (FSA)- Tri-Star
Remember: 1) Not available if you or your spouse participates in a HSA.
2) You must use the entire amount that you elect or the remaining funds will be forfeited.
If you want to contribute to the Flexible Spending Account, you may elect to have your contributions
deducted on a pre-tax basis. Do you want to participate?
Yes – Plan Year Contribution Amount $_____________ ($2,550 plan year max.)
No
Dependent Care Spending Account – Tri-Star:
Remember: 1) Available with or without a HSA
2) You must use the entire amount that you elect or the remaining funds will be forfeited.
If you want to contribute to the Dependent Care Spending Account, you may elect to have your
contributions deducted on a pre-tax basis. Do you want to participate?
Yes - Plan Year Contribution Amount $_________________($5,000 plan year max.)
No
Basic Life and AD&D – Prudential: This is a District paid benefit. Please list your beneficiary below.
Beneficiary Name
Relationship
Social
Security
Number
Date of
Birth
Primary or
Contingent
Percent (must
add up to 100%)
Trust or
Individual
Voluntary Life and AD&D – Prudential: (You will need to request an Evidence of Insurability form from Linda
Eberhardt)
Amount Newly Elected
Employee
$
Spouse
$
Child(ren)
$
Are you interested in participating in the Prudential Pathways Financial Seminars referenced on page 19?
Yes
No
How to make mid-year changes
Unless you have a qualified change in status, you cannot make changes to the benefits you elect until the next
open enrollment period. Qualified changes in status include, for example: marriage, divorce, legal separation, birth
or adoption of a child, change in child’s dependent status, death of spouse, child or other qualified dependent,
change in residence, commencement or termination of adoption proceedings, change in employment status or
change in coverage under another employer-sponsored plan.