Tufts University Parking and Transit Form

Group Name:

Group Number:

Today's Date

Effective Date

Please select one*

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security Number *

Date of Birth*

Mobile Phone Number*

Employee Email Address

example@example.com

Transit Expense Account:

Enter the Monthly Election Amount.

Pre-Tax*

(Max $325.00)

Post-Tax*

Parking Expense Account:

Enter the Monthly Election Amount.

Pre-Tax*

(Max $325.00)

Post-Tax*

I understand that:

I have elected a monthly amount which will be deducted from my paycheck(s) each month on a pre-tax and/or post-tax basis. I may change my election by submitting my request in writing or online. I understand that changes are made on a prospective basis, and that retroactive changes are not allowed. Changes received by the 4th of the month will be effective the 1st of the following month. I may claim reimbursements for eligible expenses incurred during the coverage Plan Period. Any deposits not used for claims incurred prior to the end of the Plan Year, will roll over into the next Plan Year.

Notice for Online Enrollment: As part of the enrollment process, you are required to submit a "signed" application form. Because you are submitting an electronic application, your "signature" on this application will be electronic, and you should supply us with your email address, you will receive required notices from us in electronic format as well. By submitting this application electronically, you acknowledge that you understand that your electronic "signature" is binding to the same extent as your written signature. If you have any further questions, please call our Member Services Department at the number listed below.

Call us at (888) 678-3457 Member Services
Business hours are M - F 8:00am to 4:30pm

I certify that I wish to participate in the Plan and elect to have the total amount stated above deducted from my paycheck(s). I understand this will lower my gross pay and consequently, tax base and my Social Security base.

I must continue enrollment in the Plan, with my above stated Salary Reduction Amount, unless I complete a change in Election Form. Should my required contributions for the elected benefits be increased or decreased while this agreement remains in effect, my compensation will automatically be adjusted to reflect this change.

Section 132(F) deductions are pre-tax and may not be itemized and deducted again while filing IRS Form 1040.

I provide electronic consent for EBPA to process my enrollment form and to provide notices electronically if an email address is supplied.

Please review and verify the information you provided is accurate.