Your mbi Flex Convenience® card (Card) is provided to you by your EMPLOYER
under a Benefit Plan (Plan) as allowed by the IRS under\ applicable Sections
of the Tax Codes. You may use the Card only at qualified locations for eligible
products and services under your Employer’s specific Plan. Some examples
of Plans the Card may be used with (if offered by your Employer) are: Flexible
Spending Account, Medical Savings Account, Dependent Care Account, Transit Account,
and/or Defined Contribution Plan. Depending on the Plans offered by your Employer,
examples of eligible locations for usage of the Card may include, but are not
limited to, Hospitals, Physician Offices, Dental Offices, Vision Services Locations,
Pharmacies, Dependent Care Providers, and Parking and Mass Transit.
Using your mbi Flex Convenience® card:
1. Read the front and back of this form carefully, record your Card number on
this form and retain it for your records.
2. Sign the back of your Card before using it.
3. Retain all receipts and documentation from your Flex Convenience® card
transactions to prove expenses are eligible under your Plan Guidelines and applicable
regulations established by the Internal Revenue Service. If requested by your
Employer/Plan Service Provider, you are obligated to submit your Flex Convenience®
card transaction receipts and/or any other related claim information and documentation
as deemed necessary to substantiate the eligibility status for the service/purchase.
Failure to submit such documentation may result in: 1) the expense being deemed
ineligible in which case you would be obligated to repay the amount to the Plan
and/or 2) immediate suspension or revocation of the Card; and/or 3) taxable,
payroll deductions by your Employer of the ineligible expense.
4. Visit www.TheFlexCard.com to obtain up-to-date account balance information;
to view or print your statement of activity; and/or to report your Card lost
or stolen.
IMPORTANT: When using the Card at self-service merchant terminals,
select the “credit” option. DO NOT select “debit” as
there is NO PIN NUMBER associated with this Card. Cards are ACTIVATED upon first
usage. Remember to SIGN the back of your Card before using it.
Misuse of this Card, whether intended or unintended, may result in suspension
or permanent revocation of the Card. Please contact your Employer and/or your
Plan Administrator for specific details on your Plan.
EMPLOYEE ENROLLMENT AGREEMENT
In this Agreement, the word “I”, “me” and “my”
means each employee and all of their eligible dependents. “You”
and “your” means Med-i-Bank, Inc., (dba, mbi) the provider of the
services under the Med-i-Bank Program, which enables me to use a debit-like,
stored value card (“Card”) to access coverage under pre-tax Savings
or Reimbursement “Accounts.” “Accounts” are those accounts
established, maintained and controlled by my employer or its agent, which represents
an amount of coverage under my employer’s plan(s) (“Plan”).
“Card Transaction” means each transaction at a merchant that accepts
the Card.
In connection with participating in the Program, I request that Key Bank, via
its agent, mbi, issue to me one or more Cards. I agree that each Card is the
property of Key Bank and will be surrendered to it via its agent, mbi, upon
request. I understand that I can only use the Card for payment of certain eligible
expenses defined in my Plan Document(s) and under federal tax law. Any Card
Transaction that is not for a Qualified Expenditure is called a “Non-
Qualified Expenditure”. When I use the Card, I incur an expense which
may qualify for pre-tax reimbursement under the Plan. I understand that my employer
will advance funds on my behalf to cover my expenses. You are authorized by
me to deduct the amount of each Qualified Expenditure from the Account in the
same way check transactions are handled. I further agree that Card Transactions
shall be subject to the terms of this Agreement and the rules of the Account
and any applicable federal or state rules or regulations.
You are not obligated to me if any merchant refuses to honor my Card or retains
my Card if authorization for its use is not given. I understand that if I use
my Card for a purchase which is returned for a refund, and such purchase was
a Qualified Expenditure charged to my account, such refund must be made on a
credit voucher, which shall be credited to the Account in the normal course
of business. I agree that all Card Transactions may be presented to my Plan
Administrator/Service Provider through the use of either sales or credit drafts
or electronic transmission of the transaction information, and that I will,
upon request, review transaction statements and sign documents attesting to
the validity of my Qualified Expenditures.
I understand that if I use the Card for purchases other than Qualified Expenditures, as determined by the Plan Administrator/Service Provider, the IRS, or any other party having authority, I have violated this Agreement and my obligations under my employer’s Plan. I understand that, upon notification, I must immediately re-pay the expense to my employer and that my Card may be immediately suspended or revoked for such failure to comply.
(i) all Card Transactions will be solely for Qualified Expenditures incurred
(not billed or paid) during the Plan Year in which the Card Transaction was
initiated;
(ii) the Plan Administrator/Service Provider will determine what Card Transactions
are Qualified Expenditures and that you have no responsibility to make any such
determination;
(iii) all information relating to the Account and any deductions or exclusions
from income on my federal or state tax returns and filing are my sole responsibility;
(iv) to the extent that I misrepresent any Card Transaction as a Qualified Expenditure
when it is a Non-Qualified Expenditure, whether by mistake or otherwise, I indemnify
you, and the Plan Administrator/Service Provider, and hold you harmless for
whatever penalties and consequences that may occur as a result of my actions;
(v) if I continually attempt to use the Card for Non-Qualified Expenditures,
regardless of whether such transactions are denied, I will be required to return
my Card to Key Bank’s agent, mbi, the Plan Administrator/Service Provider,
or my employer;
(vi) Qualified Expenditures for any Card Transactions have not been and will
not be reimbursed from any source other than the Account, including but not
limited to any and all insurance payments either from my insurance carriers
or my dependents’ insurance carriers;
(vii) each time I present the Card for payment, I will sign a receipt evidencing
that the expense has been incurred and reaffirming my representation that it
is a Qualified Expenditure that has not been and will not be reimbursed from
any other source.
I acknowledge and agree that upon any inappropriate or fraudulent use of the Card, or termination of employment, I will immediately return all Cards issued for use against the Account to Key Bank’s agent, mbi, the Plan Administrator/Service Provider, or my employer. If I fail to surrender all Cards, I will be responsible, to the extent permitted by law, for any Card Transactions.
If I am required to return my Card for any reason before the end of the Plan Year, I shall reimburse my employer for any amounts advanced by the employer from the Account for expenses that are not Qualified Expenditures. My employer may also pursue any and all legal means available to it to recover some or all of the amounts advanced that I am not entitled to, including but not limited to, deducting such owed amounts from subsequent payroll amounts owed me.
To the extent that any Card Transactions are not for Qualified Expenditures and I fail to reimburse the Account for such amounts, I authorize my employer to collect from me personally or withhold such funds from my pay or any other amounts due me including any taxes, fines, surcharges or penalties that may be assessed for the use of the Card for Non-Qualified Expenditures. I also understand that my Card may be immediately suspended and/or permanently revoked.
For purposes of these disclosures, your business days are Monday through Friday. Holidays are not included.
I will obtain and retain a receipt at the time I engage in a Card Transaction to verify Card purchases. I will review Transaction activity statements at least monthly, either by reviewing statements received from my Plan Administrator/Service Provider or by accessing the mbi web site, www.theflexcard.com.
Upon review, I will immediately contact my Plan Administrator/Service Provider if my Card was used for any transaction without my permission or has been lost or stolen. If my statement shows Card Transactions that I did not make (even if my Card was not lost), I must and will notify the Plan Administrator/Service Provider at once. If I do not notify the Plan Administrator/Service Provider within 60 days of the Card Transaction date, I may not recover any money I lost after the 60 days if Plan Administrator/Service Provider could have stopped someone from taking the money if I had notified Plan Administrator/Service Provider in time.
If I believe my Card was lost or stolen, or that someone has used my Card without my permission, or there appears to be an error in my statement, I will immediately call my Plan Administrator/Service Provider. I may also report my lost Card on your web site at www.theflexcard.com.
I hereby release you to provide any information necessary for the validation and/or verification of any Card Transaction, to my Plan Administrator/Service Provider. Otherwise, you will disclose information to third parties about the Account only to comply with government agency or court orders; or to verify the existence and condition of the Account for a third party, such as a merchant.
I agree that Card Transactions will be honored only when sufficient funds or coverage are available in the Account. If you or my employer, at either of your discretion, decides to pay the amount of the Card Transaction that exceeds funds in the Account, I agree to repay you or my employer in full immediately upon notice. I also agree that Card Transactions are subject to prior authorization by you or by a Card sponsoring authorization center.
You may at any time, and from time to time, upon notification, change or add to any of the terms of this Agreement. You also may cancel this Agreement and my right to use the Card any time without prior notice, but any obligation to pay any items charged against the Account, plus any applicable charges, will continue until paid in full.
By signing and using the Card, I hereby acknowledge receipt of this Employee Enrollment Agreement informing me of my rights.
Account funds do not represent deposits guaranteed, or insured by us, the issuer, or the Federal Deposit Insurance Corporation (FDIC), or any other state or federal governmental agency, and are subject to typical uninsured, non-guaranteed risk.
This Agreement shall be governed by the laws of the Commonwealth of Massachusetts,
except to the extent that federal law may apply. In the event of any conflict
between the provisions of this Agreement and any applicable law or regulation,
the provisions of the Agreement shall be deemed modified to the extent necessary
to comply with such law or regulation.