Forms

General Sales/Marketing Forms:

Broker Agreement

New Client Application

Broker Designation Form

Spending Account Forms:

FSA Enrollment Form

Limited Purpose FSA Enrollment Form

FSA Enrollment Kit

FSA Worksheet

Letter of Medical Necessity

HSA Enrollment Form

All Other HSA Forms (Directs to Website of our HSA banking partner, The Bancorp Bank)

Claim Form

Substantiation Request Form

Direct Deposit Form

HRA Enrollment Form

HRA Activation Form

CRA Change of Election Form

Plan Administrator Override Form

Employer Request for Service Form

Employee Request for Service Form

Electronic Upload Spreadsheet

COBRA Forms:

COBRA Request for Service Form

COBRA Open Enrollment Form

COBRA Rate Renewal Request Form

COBRA Participant Recurring ACH Form

ACH Authorization for Monthly Admin Fees

Takeover/Legacy QB Form

ePOP:

ePOP Online Instructions for Brokers

POP Enrollment Form

Spanish Forms/Formas en Espanol:

Claim Form/Forma de Reclamo

Substantiation Request/Solicitud de Comprobacion

FSA Enrollment Form

How to Use Your Card/Como Utilizar Su Tarjeta