Forms Library

Thank you for visiting the Employee Self-Service Forms Library.  Here you will find all of the forms necessary for claim submission, debit card management and eligible expense questions. We've created fill-able forms that provide the information you need and are easy to use and understand.

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


General Forms:  

   Change of Status

   Direct Deposit Authorization

   Change of Address Form

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Claim Forms:

The following PDF forms contain fill-able and automatic calculations, but must be printed and emailed, faxed or postal mailed after completion.  

IMPORTANT NOTE TO PARTICIPANTS: Use only the forms that correspond to your Employer's Plan as designated in your Employer's Summary Plan Description (SPD).

 

    FSA Medical Reimbursement Claim Form

    FSA Dependent Care Claim Form

           FSA Dependent Care Continuous Reimbursement Claim Form

    FSA Limited Purpose Medical Claim Form

    Health Reimbursement Arrangement (HRA) Claim Form

    Individual Health Premium Reimbursement Claim Form

    Transportation Reimbursement Claim Form

    Parking Reimbursement Claim Form

    Helpful Claim Filing Hints:

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Debit Card Forms and Tools:

   Debit Card Receipt Submission Form

   Request Spousal/Dependent Debit Card

   Debit Card Purchase Repayment Form

 

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Expense Lists

   Sample Health FSA Expenses

   Sample Dependent Care Expenses

   Detailed Eligible Expenses List

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