Estimate Annual Election

At the beginning of the plan year, you must designate how much you want to contribute. Then, your employer will deduct amounts periodically (generally, every payday) in accordance with your annual election.

Use this form to calculate how much you expect to spend (and save) on qualified expenses this year (known as your annual election). Provide the cost of each item or service listed and the number of times you expect to use it this coming year.

Tip: Hover your mouse over each item for more information.

Health Insurance Premiums
	Expense Item	Cost	Number	Amount
	Employer-Sponsored Health Insurance Plan
	Insurance Premiums (Not for Texas)
	Prepaid Insurance Premiums (Not for Texas)
	SubTotal:

Vision and Hearing Expenses
	Expense Item	Cost	Number	Amount
	Contact Lens
	Eye Examination
	Eye Glasses
	Hearing Device
	Laser Eye-Surgery
	SubTotal:

Doctor Related Expenses
- Requires written notification from a Doctor to qualify as an eligible expense.
	Expense Item	Cost	Number	Amount
	Co-Pays
	Chiropractor Services
	Diagnostic Devices
	Dietary Supplements
	Hospital Bills
	Laboratory Work
	Osteopath Services
	Orthopedic Services
	Prescriptions
	Psychologist Services
	Routine Physical
	Surgical Fees
	Weight-Loss Program
	SubTotal:

Dental Services
	Expense Item	Cost	Number	Amount
	Braces
	Dentures
	Oral Surgery
	Orthodontic Services
	Root Canals
	SubTotal:

Dependent Care Expenses
	Expense Item	Cost	Number	Amount
	Adoption Fees
	Baby-Sitter Expenses
	Day-Care Provider
	Nanny Expenses
	Nursery School
	SubTotal:

Special Medical Care
	Expense Item	Cost	Number	Amount
	Drug Addiction
	Fertility Enhancement
	Health Institution
	Mentally Retarded, Special Home for
	Nursing Home
	Nursing Services
	Oxygen
	Psychiatric Care
	Stop-Smoking Program
	Special Education
	Transportation
	SubTotal:

Your Annual Income:
Your Payroll Frequency:

Total Annual Expenses:
Annual Tax Savings:
Tax Savings per PayDay:

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Flex Services:
FREE Online Quote See how much your company will save by implementing a FamilyFlex plan.

Estimate Your Election Calculate your annual health-care expenses based on your current situation.

Qualified Expenses View a detailed list of approved expenses for FSA Plans, includ-ing Medical, Depend-ent Care, and Insur-ance Premiums.

See Also:
Dependent Care Expenses paid for the care of dependents in a Day-Care or similar provider.

HealthCare Expenses Medical expenses for diagnosis, cure, treat-ment, or prevention of disease.

Insurance Expenses Premiums paid for insurance that covers the expense of med-ical care.