Forms & Information

Use the following forms to enroll in a plan, report a change in status, or request reimbursement of a qualified expense. The forms are in Adobe Acrobat format. If you don't have Acrobat Reader, you can download a free copy here. After downloading the appropriate form, you can print the form and mail them to:

Benefits Design Group, Inc.
PO Box 370
Onalaska, WI 54650

or fax them to (608) 781-4576.

See Forms Updated for 2012 Renewal Season Below:

Flexible Spending Accounts (FSA)

The forms below should be used by Flexible Spending Account participants only.  If you have another type of program, please scroll down farther in the listing to make sure you use the correct form. 

Warning:  Use of incorrect claim forms, may DELAY your reimbursements.  Please contact our office at 1-800-342-8235 if you are unsure about which ones to use for your plan.

• Full Flex Enrollment Form Service Option #1 (New)
• Full Flex Enrollment Form Service Option # 2 (New)
• Request for Reimbursement-FSA
• Request for Reimbursement-FSA Fill-In version
• Helpful Claim Filing Hints (New)
• Examples of General-Purpose Medical Expenses (New)
• New OTC Guidelines effective January 1, 2011 (New)
• How to Keep Your Health FSA Claim Sailing Through the Reimbursement Process
• Daycare Provider Receipt
• Dependent Care Worksheet
• Employee Change Form
• Direct Deposit Authorization (New)
• Authorization for Release of Information
• HSA Certification (New)
• HSA Enrollment Form-2012 (New)
• Sample Employee Letter - FSA
• Physicians Statement (New)

Employer Forms-Flexible Spending Accounts (FSA)

• Leave of Absence Form
• Change of Status Form

Health Reimbursement Arrangements (HRA)

The forms below should be used by Health Reimbursement Arrangement (HRA) participants only.  If you have another type of program, please scroll up or down in the listing to make sure you use the correct form. 

Warning:  Use of incorrect claim forms, may DELAY your reimbursements.  Please contact our office at 1-800-342-8235 if you are unsure about which ones to use for your plan.

• Health Reimbursement Arrangement (HRA) Claim Form (NEW)
• Employee Change Form
• Direct Deposit Authorization (New)
• Authorization for Release of Information
• How to Keep Your HRA Claim Sailing Through the Reimbursement Process

Employer Forms-Health Reimbursement Arrangement

• HRA Enroll/Termination Form
• HRA Glossary of Terms/Reporting

Participants with both HRA and FSA Plans

The forms below should be used by participants who have both HRA and FSA plans only.  These participants are required to submit to the HRA program first and then any eligible claims can be resubmitted to the FSA plans authomatically.  If you have another type of program, please scroll up or down in the listing to make sure you use the correct form. 

Warning:  Use of incorrect claim forms, may DELAY your reimbursements.  Please contact our office at 1-800-342-8235 if you are unsure about which ones to use for your plan.

• HRA/FSA Claim Form (NEW)
• How to Keep Your HRA Claim Sailing Through the Reimbursement Process for HRA/FSA Plans
• Employee Change Form
• Direct Deposit Authorization (New)
• Authorization for Release of Information

Participants with both FSA and HRA Plans

The forms below should be used by participants who have both FSA and HRA plans only.  These participants are required to submit to the FSA program first and exhaust all FSA funds before claims are eligible to be processed in the HRA.  If you have another type of program, please scroll up or down in the listing to make sure you use the correct form. 

Warning:  Use of incorrect claim forms, may DELAY your reimbursements.  Please contact our office at 1-800-342-8235 if you are unsure about which ones to use for your plan.

• FSA First/HRA Second Claim Form (NEW)
• Direct Deposit Authorization (New)
• Authorization for Release of Information

Transportation Plan Forms 

• 2012 Transportation Plan Enrollment Form
• Request for Reimbursement Form - TRANS
• Transportation Plan Change of Election Form

Other Miscellaneous Forms

• Premium Only Enrollment Form