Headquarters:
400 Berwyn Park, Suite 200
899 Cassatt Road
Berwyn, PA 19312
Tel: 484-321-5800
Toll Free: 800-396-4309


Other Locations \ Directions
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August 21, 2007

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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 ecobra@eflexgroup.com or phone 608-268-5133.

Section 125 Flexible Spending Account Forms

General Forms

Fax Cover Sheet pdf
FlexCard (MBI) Card Holder Agreement pdf

Change Of Status

Change of Address pdf
Change of Status (Info) pdf
Leave of Absence Form pdf

Claim Forms

Flex Plan Claim Form pdf
eflex Debit Card Adjudication Form pdf
eflex Debit Card Claim Form pdf
Limited FSA Claim Form (for use with HSAs) pdf
2.5 Month Extension Claim Form pdf
Mileage Report pdf
Recurring Claims Explanation pdf
Recurring Claims Instructions pdf
Transportation Claim Form pdf
Fax Cover Sheet pdf

Direct Deposit Tools

Direct Deposit Authorization pdf

Dependent Care Tools

Dependent Care Worksheet pdf
Dependent Care Contract Form pdf
(Spanish)Dependent Care Contract Form pdf
Form 2441 Dependent Daycare Tax Filing Form pdf

Employee Planning Tools and Resources

Flex/HSA Eligible Expense Planning Worksheet pdf
Enrollment Form - Paper pdf
Flex Plan Worksheet pdf
IRS Publication 502 (Expenses for HSA, HRA, Flex) pdf
IRS Publication 502 (Daycare) pdf
Over-the-Counter Medical Guidelines pdf
Eflex For Me - Brochure pdf
Spanish Brochure(Daycare) pdf
Transportation Expenses Worksheet pdf

eflex Debit Card Tools

eflex Debit Card Adjudication Form (Card Purchase) pdf
eflex Debit Card Claim Form (Non-Card Purchase) pdf
Old eflex Debit Card Instructions pdf
New eflex Debit Card Instructions pdf
Request Additional eflex Debit Card
(You will receive your card in 10 days.)
html--> pdf
FlexCard (MBI) Card Holder Agreement pdf
RX Numbers on Receipts Letter pdf

Non-Discrimination Tools

Non-Discrimination Form excel

Section 105 Medical Expense Reimbursement Plan/HRA Forms

Change Of Status

Change of Address pdf
Change of Status pdf
Direct Deposit Authorization pdf
HRA/MERP Manual Claim Form pdf
HRA/MERP Enrollment Form pdf

Transportation/Mass Transit Forms

How to set up a recurring transit claim pdf
Transit employee flyer pdf
Parking Transit Enrollment Form pdf
Transportation Claim Form pdf
Transportation Worksheet pdf
Transportation Claim Form (Spanish) pdf
Parking Transit Enrollment Form (Spanish) pdf

En Español

Educativa para EmpleadoEducativa para Empleado
  Employee Education
pdf
Referencia de Medicamentos Sin Receta
  Over-the-Counter Reference
pdf
Preguntas con mas Frequencia FSA
  Frequently Asked FSA Questions
pdf
Forma de Inscripcion de FSA
  FSA Enrollment Form
pdf
Circular Educativa para Tarjeta Debito
  Employee Debit Card Education Flyer
pdf
Formulario de Reclamación de Transporte
  Transportation Claim Form
pdf
Parking de Tránsito Formulario de Inscripión
  Parking Transit Enrollment Form (Spanish)
pdf
Cuenta FSA para el Cuidado de Dependientes
  Dependent Care FSA Flyer
pdf
Reclamos Recurrentes
  Recurring Claims Information
pdf
Contrato de Cuidado de Dependientes
  Dependent Care Contract
pdf