FORMS AND INSTRUCTIONS

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.

Flexible Spending Accounts (FSA)

• Full Flex Enrollment Form Service Option #1 *Now Fill In Online*
• Full Flex Enrollment Form Service Option # 2 *Now Fill In Online*
• Request for Reimbursement-FSA
• Helpful Claim Filing Hints
• Examples of Unreimbursed Medical Expenses
• Guidelines When Claiming OTC Medications
• How to Keep Your Health FSA Claim Sailing Through the Reimbursement Process
• Daycare Provider Receipt
• Dependent Care Worksheet
• Employee Change Form
• Direct Deposit Authorization
• Authorization for Release of Information
• HSA Certification
• Sample Employee Letter - FSA
• Physicians Statement

     Employer Forms

• Leave of Absence Form
• Change of Status Form

Health Reimbursement Arrangements (HRA)

• Section 105 Reimbursement Claim Form
• Employee Change Form
• Direct Deposit Authorization
• Authorization for Release of Information
• How to Keep Your HRA Claim Sailing Through the Reimbursement Process

     Employer Forms 

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

Participants with both HRA and FSA Plans

• Section 105/125 Reimbursement Claim Form
• How to Keep Your HRA Claim Sailing Through the Reimbursement Process for HRA/FSA Plans
• Employee Change Form
• Direct Deposit Authorization
• Authorization for Release of Information

Transportation Plan Forms

• 2009 Transportation Plan Enrollment Form
• 2010 Transportation Plan Enrollment Form
• Request for Reimbursement Form - TRANS
• Transportation Plan Change of Election Form

Other Miscellaneous Forms

• Premium Only Enrollment Form