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Home  > Forms > Section 125 FSA Forms
Section 125, Section 105 Administration, COBRA Administration

About Our Forms

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.

We are sincerely sorry for any inconvenience that you may have had with the earlier versions of the Adobe Acrobat forms.

 

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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
HTML Change of Address
PDF Change of Address
  Change of Status (C.O.S. Qualifications)
HTML Change of Status
PDF Change of Status
  Leave of Absence Form
PDF 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 
PDF Reimbursement Claim Form
  eflex Debit Card Adjudication Form
HTML MBI Adjudication Form
PDF MBI Adjudication Form
  Mileage Report
PDF Mileage Report
  Recurring Claims Explanation
PDF Recurring Claims Explanation
  Recurring Claims Instructions
PDF Recurring Claims Instructions
  Fax Cover Sheet PDF Fax Cover Sheet

Direct Deposit Tools
  Direct Deposit Authorization
PDF Direct Deposit Authorization

Dependent Care Tools
  Dependent Care Worksheet
PDF Dependent Care Worksheet
  Dependent Care Contract Form
HTML Dependent Care Information
PDF Dependent Care Information
  (Spanish)Dependent Care Contract Form
PDF Dependent Care Information(Spanish)
  Form 2441 Dependent Daycare Tax Filing Form
PDF IRS Form 2441 (Daycare)

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

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

Non-Discrimination Tools
  Non-Discrimination Form
Microsoft Excel or equiv. required

 
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