 FORMS can be printed, downloaded, completed and faxed or mailed back to us. Address and fax information is provided on each form.PDF files require Adobe Reader for viewing. Adobe Reader can be downloaded for free at: http://www.adobe.com/products/acrobat/readstep2.html
FSA-Flex Spending Account
New Enrollee General Information:
File:
New Participant Welcome to FSA-Healthcare Information: |
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File:
New Participant Welcome to FSA-Dependent Care
Information: |
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FSA-Flex Spending Account ENROLLMENT Forms:
File: FSA-Enrollment-Authorization Form
(This is a generic form, call CPA Inc if you need information on your plan specs): |
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File: FSA-City of Boston Enrollment-Form (For OPEN Enrollment
Use Only): |
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File: FSA-City
of Boston Employee
Change of Status Form (For Qualifying changes/New Hire Form): |
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File: FSA-City of
Cambridge Enrollment
Form (For OPEN Enrollment
Use Only): |
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File: FSA-Cambridge Schools Enrollment
Form (For OPEN Enrollment
Use Only): |
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FSA-Flex Spending Accounts CLAIM Forms:
File: FSA-Healthcare Claim Reimbursement Form: |
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File: FSA-Dependent Care Claim/Certification Form: |
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TRANSPORTATION & PARKING PLANS CLAIM Form:
File: Qualified Transportation and Parking Claim Form: |
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FSA-Flex Spending Accounts
MISCELLANEOUS Forms:
File: Direct Deposit Sign-up Form: |
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File: FSA-Over-the-Counter
Items now ELIGIBLE: |
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File: FSA-Required Physician's Letter: |
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File: FSA-Eligible Expenses List: |
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File: FSA-Employee
Change of Status Form: |
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HRA-Reimbursement Forms: (Not for use for FSA FLEX plans):
File: Direct Deposit Sign-up Form: |
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File: HRA Generic - Claim Reimbursement Form: |
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File: HRA- Town of
Wellesley (custom) Claim Reimbursement Form |
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File: HRA- Town of Wellesley - Retirees (custom) Claim Reimbursement Form |
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POP-Premium Only Plan Account Forms (Not for use for FSA FLEX plans):
File: POP-Section 125 Enrollment-Authorization Form: |
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