FLEXIBLE BENEFITS FORMS

GB-02 2017 Flexible Spending Arrangement Enrollment Form

The plan member must complete this form each year during annual enrollment to enroll into a Flexible Spending Arrangement (FSA). New hires have 30-days in which to decide to enroll in a FSA and complete this form.

2017 Recurring Dependent Care Request Form

Plan members enrolled in a Dependent Care FSA must use this form for recurring dependent expenses.

Discovery Benefits – Authorized Representative Form

This form designates one or more authorized representative for a plan member in case the plan member is incapable of making a decision.

Qualified Reservist Distribution Request Form

A Qualified Reservist Distribution (QRD) is a refund made to an employee of all or a portion of the balance remaining in the employee’s unused General-Purpose Health Care Flexible Spending Arrangement (GPFSA) or Limited-Purpose Dental/Vision Flexible Spending Arrangement (LPFSA) account. To qualify for a QRD, the employee must be a member of a reserve unit ordered to active duty for a period of 180 days or more, or for an indefinite period of time.

Out-of-Pocket Reimbursement Request Form

Plan members participating in a Flexible Spending Arrangement (FSA) can use this form for reimbursement of any out-of-pocket expenses where the Discovery Benefits debit card was not used. Documentation to substantiate purchases must accompany the form whether the form is mailed or faxed.