Forms

Employer

Flexible Spending Account

Flexible Spending Account Employee Enrollment Form.pdf Form to complete for employee to be enrolled in Medical and/ or Dependent Care FSA

Limited Flexible Spending Account Employee Enrollment Form.pdf Form to complete for employee to be enrolled in Medical, Limited, and/ or Dependent Care FSA

Flexible Spending Account Change in Status Form.pdf Form to report an employee change in status and corresponding election adjustment for the Flexible Spending Account


Dependent Care Reimbursement Account

Dependent Care Reimbursement Account Employee Enrollment Form.pdf Form to complete for employees enrolling only in the Dependent Care FSA


Health Reimbursement Arrangement

Health Reimbursement Arrangement Bridge Plan Employee Enrollment Form.pdf Form to complete for employee to be enrolled in Bridge HRA

Health Reimbursement Arrangement Comprehensive Plan Employee Enrollment Form.pdf Form to complete for employee to be enrolled in Comp HRA


Transit Plan

Transportation Plan Employee Enrollment Form.pdf Form to complete for employee to be enrolled in Transit reimbursement account


Health Savings Account

Health Savings Account Employee Contribution Change Form.pdf Form to report an employee contribution change for the HSA Bank Health Savings Account

Health Savings Account Employee Enrollment Form.pdf Form to complete for employee to be enrolled in Health Savings Account with other custodial banks (5/3rd or BB&T)


COBRA and Retiree Billing

COBRA Employer Qualifying Event Notification Form.pdf Form to complete to report a Qualifying Event and generate a COBRA Qualifying Event notice

COBRA New Hire Notification Form.pdf Form to complete to report a new COBRA eligible employee and generate a COBRA Initial Notice

Employee

Flexible Spending Account

Employee Claim Form for Flexible Spending Account.pdf Form to complete to file for reimbursement of qualified expenses under your Medical, Limited, and /or Dependent Care Flexible Spending Account

ACH Direct Deposit Form.pdf Form to complete and return to BMS to set up ACH Direct Deposit of reimbursements

Flexible Spending Account Worksheet.pdf Worksheet to help calculate potential participant contribution and savings for the Flexible Spending Account

Flexible Spending Account Qualified Expenses List.pdf Broad list of potentially qualifying expenses for reimbursement from the Flexible Spending Account

FSA Eligibility List Valid for FSA, HSA and general-HRA expenses

Dependent Care Reimbursement Account

Employee Claim Form for Dependent Care Reimbursement Account.pdf Form to complete to file for reimbursement of qualified childcare expenses under your Dependent Care Flexible Spending Account


Health Reimbursement Arrangement

Employee Claim Form for Health Reimbursement Arrangement.pdf Form to complete to file for reimbursement of qualified expenses under your HRA


Health Savings Account

Employee Claim Form for Health Savings Account.pdf Form to complete to file for reimbursement of qualified expenses under your HSA


Transit Plan

Employee Claim Form for Transit Plan.pdf Form to complete to file for reimbursement of qualified transportation expenses under your Transit Plan