FSA Limit Increase Request

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
To take advantage of the expanded limits, plan sponsors must amend their plans to reflect the new limit.

Plan Type	2023 Plan Year	2024 Plan Year
Health FSA / Limited FSA	$3,050	$3,200
FSA Rollover Limits for 2023 into 2024	$610	$640
Dependent Care FSA	$5,000	$5,000

If completing this form for a future plan year before limits are released by the IRS, you are authorizing BRI to align your plan limits to the maximum limits when released from the IRS.

Question Title

1. Please select the plan year limits should apply to.

Question Title

2. Authorization to change 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 Plan Year election limit for a Health FSA and/or Limited FSA:

Increase the allowable election limit for a Health FSA / Limited FSA to the statutory limit as released by IRS.

No change to the election limit for Health FSA / Limited FSA Limit

Change election limit for Health FSA / Limited FSA to another specified amount (please specify)

Question Title

3. 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 Plan Year selected above from a Health FSA and/or Limited FSA.

Update the eligible FSA Rollover amount to the Statutory Limit as released by IRS.

I do not wish to make a change to the FSA Rollover limit / we do not use the rollover option.

Change FSA Rollover Limit to another specified amount, not to exceed the statutory limit. Please specify.

Question Title

4. Company / Plan Sponsor Information

Contact Name

Company / Plan Sponsor

Email Address

Phone Number

Question Title

1. Please select the plan year limits should apply to.

Question Title

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

Question Title

3. 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 Plan Year selected above from a Health FSA and/or Limited FSA.

Question Title

4. Company / Plan Sponsor Information

2. Authorization to change 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 Plan Year election limit for a Health FSA and/or Limited FSA:

3. 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 Plan Year selected above from a Health FSA and/or Limited FSA.