FLEXIBLE BENEFITS FORMS


GB-02 2022 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.

Recurring Dependent Care Request Form

Plan members enrolled in a Dependent Care FSA must use this form for recurring dependent expenses. It must be completed each year you enroll and re-enroll in the Dependent Care FSA.

Summit Debit Reimbursement Substantiation Form

FSA LPFSA Reimbursement Claim Form

DCAP Reimbursement Claim Form

Optum Financial FSA Claim Form (Effective June1, 2022)

Optum Financial Dependant Care Claim Form (Effective June1, 2022)