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Forms for Employers

Employee Hires/New Participants

Form NameForm DescriptionCan I Do This Online?
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
Flex Card Information and Enrollment Form for Employees 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)  
HSA Guide Information for new HSA participants  

 

Existing Participants

Form NameForm DescriptionCan I Do This Online?
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

Form NameForm DescriptionCan I Do This Online?
Enrollment Guide & Plan Participation Form Used by participants to enroll in Flexible Spending Accounts  
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 Change Form Submit to ProBenefits if your bank account has changed  
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