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Quick Forms

This form is used to request reimbursement from your account and must be accompanied by proof of the expense that you are requesting the reimbursement for.

Employer Forms

This checklist is used when setting up any type of reimbursement plan.

This form explains the terms of our agreement.

Information Checklist
This is the checklist of items we need to install any of the plans.

This form should be used for employees to make Elections and Election changes to their HRA and/or FSA plan.

Refer another business to receive a discount on your fees

Employee Forms

This form will allow an employee to make a change to their election if they have a qualifying event.

Use this form to sign up an employee for FSA or HRA COBRA coverage.

This form is used to submit a Request for Reimbursement from your Dependent Care Account.

This form shows IRS Eligible Section 213(d) Expense descriptions and documentation required for Standard FSA Plans, Limited Purpose FSA Plans, and HRA Plans.  NOTE: not all expenses may be eligible for your plan; please refer to your Employers Summary Plan Description for a list of eligible benefits your plan covers.

This form is used by the employees prior to the begining of each new plan year to elect the benefits the are participating in.

Use this form for Over-the-Counter purchases that require a Doctors Letter of Medical Determination Form. Have your provider complete and return with your claim submission.

This is a news release regarding Over The Counter Drugs. Also check out of which we have a link on this site.