Instructions

Please complete the below form to make changes to the limits for an existing benefit administered by Benefit Resource. If you would like to add or change a plan, please reach out to your Assigned Representative. 
Reference Information on the Limits for 2023
To take advantage of the expanded limits, plan sponsors must amend their plans to reflect the new limit. 

Plan Type 2022 Plan Year 2023 Plan Year
Health FSA / Limited FSA  $2,850 $3,050
FSA Rollover Limits for 2023 into 2024 $570 $610
Dependent Care FSA  $5,000 $5,000

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1. Authorization to change 2023 election limit for Health FSA  and/or Limited FSA
I, on behalf of the company listed below, authorize Benefit Resource, LLC to make the following change to our 2023 Plan Year election limit for a Health FSA and/or Limited FSA: 

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2. Authorization to change eligible rollover amount from Health FSA and/or Limited FSA.
I, on behalf of the company listed below, authorize Benefit Resource, LLC to make the following change to the eligible rollover amount for the 2023 Plan Year from a Health FSA and/or Limited FSA.

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3. Company / Plan Sponsor Information

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