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, Microsoft Word 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.

Census Spreadsheets

- Combo Plans (Microsoft Excel)   - FSA & DCAP (Microsoft Excel)   - HRA Only (Microsoft Excel)   - POP Only (Microsoft Excel)

Data Gathering Forms

- Combo Plans (Microsoft Word)   - FSA & DCAP (Microsoft Word)   - HRA Only (Microsoft Word)   - POP Only (Microsoft Word)

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

- Employer Brochure (PDF)   - Employee Brochure (PDF)   - Enrollment Agreement (PDF)   - Check Stuffer (PDF)   - Parameter Setup Form (PDF)   - Settlement Account Application (Microsoft Word)   - FSA Processing FAQs (PDF)   - General FAQs (PDF)