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Home  > Forms > Section 105 MERP/HRA Forms
Section 125, Section 105 Administration, COBRA Administration

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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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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 
PDF Reimbursement Claim Form
  Change of Address
HTML Change of Address
PDF Change of Address
  Change of Status
HTML Change of Status
PDF Change of Status
  Direct Deposit Authorization
PDF Direct Deposit Authorization
  HRA/MERP Enrollment Form
HTML HRA Enrollment Form
PDF HRA Enrollment Form
  HRA/MERP Termination Form
PDF Participant Termination Form

 
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