Forms
If you encounter any problems using these forms please feel free to contact us at 1.877.933.3539.
COBRA Forms
Note: All COBRA forms are now available at www.eCOBRAdmin.com.
You must have your eCOBRAdmin.com username and password to access the forms. If you have lost or forgotten your eCOBRAdmin.com username or password, please contact cobra specialist at cobra@eflexgroup or phone 608-268-5133.
Section 125 Flexible Spending Account Forms
Change Of Status |
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| Change of Address | html | |
| Change of Status (Info) | html | |
| Leave of Absence Form | ||
Claim Forms |
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| Flex Plan Claim Form | html | |
| eflex Debit Card Adjudication Form | html | |
| eflex Debit Card Claim Form | html | |
| eflex Debit Card Lost Receipt Form | html | |
| Limited FSA Claim Form (for use with HSAs) | ||
| 2.5 Month Extension Claim Form | ||
| Mileage Report | ||
| Recurring Claims Explanation | ||
| Recurring Claims Instructions | ||
| Transportation Claim Form | html | |
| Fax Cover Sheet | ||
Direct Deposit Tools |
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| Direct Deposit Authorization | ||
Dependent Care Tools |
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| Dependent Care Worksheet | ||
| Dependent Care Contract Form | html | |
| (Spanish)Dependent Care Contract Form | ||
| Form 2441 Dependent Daycare Tax Filing Form | ||
Employee Planning Tools and Resources |
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| Flex/HSA Eligible Expense Planning Worksheet | ||
| Enrollment Form - Paper | ||
| Flex Plan Worksheet | ||
| IRS Publication 502 (Expenses for HSA, HRA, Flex) | ||
| IRS Publication 502 (Daycare) | ||
| Over-the-Counter Medical Guidelines | ||
| Eflex For Me - Brochure | ||
| Spanish Brochure(Daycare) | ||
| Transportation Expenses Worksheet | ||
eflex Debit Card Tools |
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| eflex Debit Card Adjudication Form (Card Purchase) | html | |
| eflex Debit Card Claim Form (Non-Card Purchase) | html | |
| Old eflex Debit Card Instructions | ||
| New eflex Debit Card Instructions | ||
| eflex Debit Card Lost Receipt Form | html | |
| Request Additional eflex Debit Card (You will receive your card in 10 days.) |
html | |
| FlexCard (MBI) Card Holder Agreement | html | |
| RX Numbers on Receipts Letter | ||
Non-Discrimination Tools |
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| Non-Discrimination Form | excel | |
Section 105 Medical Expense Reimbursement Plan/HRA Forms
Change Of Status |
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| Change of Address | html | |
| Change of Status | html | |
| Direct Deposit Authorization | ||
| HRA/MERP Online Claim Form | html | |
| HRA/MERP Manual Claim Form | ||
| HRA/MERP Enrollment Form | html | |
Section 105 Medical Expense Reimbursement Plan/HRA Forms
Transportation/Mass Transit Forms |
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| How to set up a recurring transit claim | ||
| Transit employee flyer | ||
| Parking Transit Enrollment Form | ||
| Transportation Claim Form | html | |
| Transportation Worksheet | ||
| Transportation Claim Form (Spanish) | ||
| Parking Transit Enrollment Form (Spanish) | ||
Section 125 Flexible Spending Account Forms
General Forms |
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| Fax Cover Sheet | ||
| FlexCard (MBI) Card Holder Agreement | html | |
