Participant Forms - updated for 2011

The following are some forms that you can view and print out for your convenience. These are .pdf files so you must use Adobe Acrobat Reader to view and print the forms. If you do not have Adobe, click on the icon below to download it.

Section 125 Medical/Dependent Care Reimbursement Accounts:

Off Calendar Year Enrollment Form:	If your employers plan year is not on a calendar basis then, use this application to enroll in your company's Flexible Spending Plan. Sign up and enjoy the benefits of paying for eligible expenses on a pre-tax basis.
Standard Medical and Dependent Care Reimbursement Claim Form:	Used to request reimbursement for Medical and/or Dependent Care claims. Valid receipts must be attached. Sorry, cancelled checks or credit card receipts cannot be accepted.
Instructions for Medical and Dependent Care Reimbursement Claim Form:	Provides detailed directions on how to complete the form for reimbursement of eligible pre-tax Medical and Dependent Care expenses.
Grace Period Medical Reimbursement Claim Form:	For use only by employees that participate in a Medical FSA in which their employer has chosen to implement a GRACE PERIOD EXTENTION. This form is used to request reimbursement for Medical claims. Be sure to indicate from which year you wish to have funds reimbursed. Valid receipts must be attached. Sorry, cancelled checks or credit card receipts cannot be accepted.
Instructions for Grace Period Medical Reimbursement Claim Form:	Detailed directions for Grace Period participants on how to complete the form for reimbursement of eligible pre-tax Medical expenses.
Grace Period Dependent Care Reimbursement Claim Form:	For use only by employees that participate in a Dependent Care Assistance Program (DCAP) in which their employer has chosen to implement a GRACE PERIOD EXTENTION. This form is used to request reimbursement for Dependent Care claims only. Be sure to indicate from which year you wish to have funds reimbursed. Valid receipts must be attached. Sorry, cancelled checks or credit card receipts cannot be accepted.
Flexible Spending Account Change Application:	Used when a change in status has occurred during a plan year. Please keep in mind, in order to alter your election a valid change in status must have occurred, see page two for details.

Health Reimbursement Arrangements (HRA)

HRA Claim Form:	Used to request reimbursement for Medical claims. Valid receipts/EOB’s must be attached. Sorry, cancelled checks or credit card receipts cannot be accepted.
HRA Claim Form Instructions:	Instructions on how to request reimbursement for Medical claims.
Pay to Provider Form:	USE ONLY IF YOUR COMPANY HAS AN HRA PLAN AND PERMITS BENEFLEX TO PAY YOUR CARE PROVIDER DIRECTLY. If participating in such a plan then, this form is used to request reimbursement for Medical claims or Pay-to-Provider. Valid receipts/EOB’s must be attached. Sorry, cancelled checks or credit card receipts cannot be accepted.
Pay to Provider Form Instructions:	Pay-to-Provider Instructions on how to request payment to a care provider or reimbursement for Medical claims.

Section 132 Mass Transit/Parking Reimbursement Accounts:

Mass Transit and Parking Enrollment Form:	Use this application to enroll in your company’s Mass Transit and/or Parking Plan. Sign up and enjoy paying for eligible expenses on a pre-tax basis. If your company has additional pre-tax Plans that you wish to enroll in use the Flexible Spending Account Enrollment Form.
Mass Transit and Parking Reimbursement Log and Claim Form:	Used to request reimbursement for pre-tax and/or post-tax Mass Transit and/or Parking claims.
Instructions for Mass Transit and Parking Reimbursement Log and Claim Form:	Directions on how to complete the form for reimbursement of eligible pre-tax and/or post-tax Mass Transit and Parking expenses.

Other:

Direct Deposit Agreement/Enrollment Form:	Use for Direct Deposit setup, change or cancellation.
Cardholder Agreement: