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.
This form explains the terms of our agreement.
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.
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 is a news release regarding Over The Counter Drugs. Also check out www.FSAstore.com of which we have a link on this site.
Dependent Care Claim Form
This form is used to submit a Request for Reimbursement from your Dependent Care Account.
Dependent Care Receipt
This form is used by an employee to show they incurred an eligible expense for Dependent Care.
This form is used by the employees prior to the begining of each new plan year to elect the benefits the are participating in.
Employee Account Access
This form gives instruction on how to access an employees account through the Client Login Button.
Qulified Transportation Change Form
This for allows an employee to make changes to their Qualified Transportation and Parking elections.
This form will allow an employee to make a change to their election if they have a qualifying event.