Flexible Benefits Plan Forms

Certificate of Qualifying Dependent Care Expenses (pdf 23kb)

Change in Election (pdf 24kb)

Debit Card Substantiation Form (pdf 112kb)

DCFSA Eligible Expenses (pdf 15kb)

Direct Deposit Authorization (pdf 14kb)

Enrollment Form (pdf 19kb)

Flexible Benefits Plan Application (pdf 34kb)

HCFSA Reimbursement Checklist (pdf 22kb)

HCFSA Eligible Expenses (pdf 22kb)

HSA - Eligible Expenses (pdf 16kb)

Medical Expense Estimation Worksheet (pdf 20kb)

Notice of Termination (pdf 10kb)

Over-the-Counter Health Care Items (pdf 18kb)

Participation - Terms and Conditions (pdf 15kb)

Reimbursement Request (pdf 22kb)

Waiver of Participation (pdf 18kb)

Health Reimbursement Arrangements Forms

Direct Deposit Authorization (pdf 15kb)

Enrollment Form (pdf 20kb)

Health Reimbursement Arrangement Application (pdf 31kb)

Notice of Termination (pdf 9kb)

Reimbursement Request (pdf 20kb)