BSI Administrative Services: GET FORMS

Form PR2: Annual Election Form Front
Form PR2b: Annual Election Form Back
Form PR3: Claims Reimbursement Form
Form PR3b: Claims Reimbursement Form Instructions
Form PR4: Request for Transportation Claim Reimbursement Form
Form PR5: Termination Form
Form PR6: Change of Election Form
Form WS1: Enrollment Worksheet 1 – Unreimbursed Healthcare
Examples of Over-the-Counter Items
Form WS2: Enrollment Worksheet 2 – Child/Dependent Care
Form DDA: Direct Deposit Authorization
Form H: How Do You Benefit
Form P: Proof of Payment

These Limited Purpose FSA forms can be used if you have a Heath Savings Account Plan effective September 1, 2010:

Form PR2fsa: LPFSA Election Form
Form PR3fsa: LPFSA Claims Reimbursement Form
Form PR3bfsa: LPFSA Claims Reimbursement Form Instructions

These claim forms can be used for services dated from September 1, 2009 until August 31, 2010 to be used for the Limited Purpose FSA Plan:

Form PR3fsa: LPFSA Claims Reimbursement Form
Form PR3bfsa: LPFSA Claims Reimbursement Form Instructions

If you do not have an HSA, thus use the Unreimbursed Healthcare account for the Plan Year ended June 30, 2010 (instead of the Limited Purpose FSA) these claim forms can be used for services dated from July 1, 2009 until the Grace Period ending September 15, 2010:

Form PR3: Claims Reimbursement Form
Form PR4: Request for Transportation Claim Reimbursement Form