Resources

FSA Claim Form

Download419 KB

Flex Made Easy FSA Flyer

Download2 MB

HIPAA Release Form

Download192 KB

IRS Form W-10 (Dependent Care Provider’s identification)

IRS Form 2441 (for Dendent Care participants to fill out and submit with their Federal Tax return)

IRS Publication 503 (dependent care expense)

IRS Publication 502 (medical expenses)

HSA Transfer Form

Download407 KB

Letter of Medical Necessity

Download333 KB

Premium Reimbursement Account Claim Form

Download371 KB

Recurring Dependent Care Expense Request Form

Download561 KB

Flexible Spending Account Claim Form

Download526 KB

4551 W. 107th Street, Suite 310
Overland Park, KS 66207
Toll-Free: (855) 615-3679
Fax: (866) 686-3539

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Disclosures

The information provided herein only represents a summary of plan features that may be available. Since health insurance plans and rates may vary, please consult the plan documents for the most descriptive and current information. Certain exclusions and limitations may apply. The examples and figures provided herein are for illustrative purposes only. The Company reserves the right to amend the benefits provided to employees at any time at its discretion to the extent permitted by law. The Company does not provide tax or investment advice. The information provided herein does not create a contract of employment.