Download a Form
Participants - FSA |
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| Claim Form: Fill & Print | Fill out on your computer, then print and submit with your documentation |
| Claim Form: Print a Blank Form | Print a blank claim form to fill out by hand, then submit with your documentation |
| Claims Guidebook | Learn more about how to use your Flexible Spending Account |
| Enrollment Guide & Plan Participation Form | Complete with your administrator to enroll in Flexible Spending Accounts |
| Enrollment Guide Update | Important update to the Enrollment Guide concerning FSA Eligible Expenses |
| Direct Deposit Authorization | Complete and submit to have your reimbursements deposited directly into your checking or savings account (if offered by your plan) |
| Flex Card Information and Enrollment Form | Request a Flex Debit Card to pay for eligible expenses (if offered by your plan) |
| Orthodontia Reimbursement | Learn about the newly revised FSA rules for orthodontia reimbursement |
| Prenatal Care/Delivery: Memo and Provider Letter | Learn about FSA rules for Prenatal Care and Delivery |
| Medical Mileage Worksheets: 2009, 2010 | Use these worksheets to determine your Medical Mileage reimbursement |
Participants - HRA/MERP |
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| HRA/MERP Claim Form: Fill & Print | Fill out on your computer, then print and submit with your documentation |
| HRA/MERP Claim Form: Print a Blank Form | Print a blank claim form to fill out by hand, then submit with your documentation |
Benefit Administrators |
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Employee Hires/
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| New Hire/Status Change Form: Print a Blank Form | Complete and submit with Participation/Waiver form for new hires or newly eligible employees |
| New Hire/Status Change Form: Fill & Print | Fill out on your computer, then print, sign and submit. |
| FSA Plan Participation/Waiver Form Only or FSA Enrollment Guide & Form |
Complete with new hires or newly eligible employees |
| Special FSA Participation Form | Complete and submit to allow limited dental and vision participation by employees who have HSAs, or participation by employee only or employee plus children only for employees whose spouses have HSAs. |
| Direct Deposit for Employees | Complete and submit for new participants if your plan offers direct deposit of reimbursements |
| Complete and submit for new participants if your plan offers the Flex Card | |
| Premium-Only Waiver Form | Allow employees to opt out of pre-taxing insurance premiums |
| Core Medical Coverage Waiver Form | Allow employees to waive employer-sponsored medical insurance coverage with proof of equivalent coverage |
| Pre-Tax Premium Notification Form | Notice of hiring, termination or changes affecting pre-tax premiums |
| Flex Planning Worksheet | Use to help employees estimate their FSA needs (also found in the FSA Enrollment Guide) |
Existing Participants |
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| Status Change Form | Request for participant election change due to a qualifying change of status |
| Employee Termination Notice | Submit promptly to notify ProBenefits of participant termination of employment |
| Certificate of Creditable Coverage | Certificate of Creditable Coverage for terminating participants |
Plan Startup/Re-Enrollment |
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| Enrollment Meeting Interest Flyer | Post in your office to notify employees of upcoming enrollment meetings |
| Employee Census Spreadsheet | Use to submit employee data to ProBenefits |
| Employer Bank Account Setup | Provide reimbursement account information to ProBenefits |
| Sample Letter to Disability Insurance Carrier | Sample Long Term Disability coverage verification letter |
| Sample Flex Plan Announcement Letter | Announce the Flexible Benefit Plan option to your employees |
| POP Announcement Letter (Startup) | Announce the Premium Only pre-tax benefit to your employees |
| POP Announcement Letter (Renewal) | Remind your employees of the Premium Only pre-tax benefit |
| Bank Draft of Fees - Authorization Form | Complete and submit to allow ProBenefits to draft monthly fees directly from your bank account |