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Section 125, Section 105 Administration, COBRA Administration

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Please note that all of our forms are now in HTML and PDF format. The HTML forms can be filled out then printed; the PDF forms can be printed, then filled out.

To view or print the PDF files, you'll need a free utility called Adobe Reader.

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eflexgroup.com Web Forms

If you encounter any problems using these forms please feel free to contact us at 877.933.3539.

Section 125 Flexible Spending Account Forms

		HTML	pdf
Change Of Status
	Change of Address
	Change of Status (C.O.S. Qualifications)
	Leave of Absence Form

Claim Forms
We are excited to introduce an all-inclusive reimbursement claim form for all of your plans with eflexgroup.com. The new claim form will allow us to move to optical character recognition of claims, thereby decreasing claims reimbursement turnaround time. The new form utilizes Adobe Acrobat's fillable forms feature. Once completed, the form should be printed and faxed to eflexgroup.com's claims department at the number listed on the form.
	Reimbursement Claim Form
	eflex Debit Card Adjudication Form
	Mileage Report
	Recurring Claims Explanation
	Recurring Claims Instructions
	Fax Cover Sheet

Direct Deposit Tools
	Direct Deposit Authorization

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

Employee Planning Tools and Resources
	FSA Frequently Asked Questions
	Flex/HSA Eligible Expense Planning Worksheet
	Enrollment Form - Paper
	Flex Plan Worksheet
	IRS Publication 502 (Expenses for HSA, HRA, Flex)
	IRS Publication 503 (Daycare)
	Over-the-Counter Medical Guidelines
	Spanish Brochure
	Transportation Expenses Worksheet

eflex Debit Card Tools
	eflex Debit Card Adjudication Form (Card Purchase)
	FSA Debit Card Instructions
	HSA Debit Card Instructions
	eflex Debit Card Lost Receipt Form
	Request Additional eflex Debit Card (You will receive your card in 10 days.)
	FlexCard (MBI) Card Holder Agreement
	Debit Card Dispute Guide

Non-Discrimination Tools
	Non-Discrimination Form

Section 105 Medical Expense Reimbursement Plan/
Health Reimbursement Arrangement Forms

		HTML	pdf
We are excited to introduce an all-inclusive reimbursement claim form for all of your plans with eflexgroup.com. The new claim form will allow us to move to optical character recognition of claims, thereby decreasing claims reimbursement turnaround time. The new form utilizes Adobe Acrobat's fillable forms feature. Once completed, the form should be printed and faxed to eflexgroup.com's claims department at the number listed on the form.
	Reimbursement Claim Form
	Change of Address
	Change of Status
	Direct Deposit Authorization
	HRA/MERP Enrollment Form
	HRA/MERP Termination Form

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.

Transportation/Mass Transit Forms

		HTML	pdf
We are excited to introduce an all-inclusive reimbursement claim form for all of your plans with eflexgroup.com. The new claim form will allow us to move to optical character recognition of claims, thereby decreasing claims reimbursement turnaround time. The new form utilizes Adobe Acrobat's fillable forms feature. Once completed, the form should be printed and faxed to eflexgroup.com's claims department at the number listed on the form.
	Reimbursement Claim Form
	How to set up a recurring transit claim
	Transit employee flyer
	Parking Transit Enrollment Form
	Transportation Worksheet
	Transportation Claim Form (Spanish)
	Parking Transit Enrollment Form (Spanish)

General Forms

		HTML	pdf
	Fax Cover Sheet
	FlexCard (MBI) Card Holder Agreement
	Medical Necessity Letter