Please note that the forms listed below are general and may not apply to the benefits offered by your employer. The forms require Adobe Acrobat Reader or Microsoft Excel. If you do not have Adobe Acrobat installed on your computer, you can download it for FREE by clicking on the logo below. Should you require any further assistance, please feel free to contact us via email at customerservice@ebeneadmin.com or call us toll-free at 800.494.6804.

Claim Filing Forms & Documents

- Eligible/Ineligible Expenses List (PDF)   - Claim Filing Instructions (PDF)   - Valid Receipt Requirements (PDF)   - DCAP & FSA Claim Form (PDF)   - HRA Claim Form (PDF)   - Letter of Medical Necessity (PDF)

Change of Status Forms & Documents

- Section 125, HRA and/or COBRA Form (PDF)

Section 125 Cafeteria Plan Enrollment Forms & Documents

- Election Form and Compensation Reduction Agreement (PDF)   - Direct Deposit Authorization Form (PDF)   - FSA Expenses Worksheet (PDF)

mySourceCard® MasterCard® Debit Card Forms & Documents

- Employee Brochure (PDF)   - Enrollment Agreement (PDF)   - FSA Processing FAQs (PDF)   - General FAQs