Broker Forms
These forms should be printed, filled out & signed.
Then fax or mail as per instructions on the individual forms.
FLEX Forms
- Flex Plan Setup Sheet
- Flex POP Setup Sheet
- FLEX Worksheet
* To assist you with computing your annual enrollment - Flex Enrollment
* For enrollments and re-enrollments - FLEX Enrollment Change
* New baby or other life changing events? - Please let us know! - Flex Reimbursement Request
* use when filing a manual claim - FLEX Eligible Reimbursable Expenses
- Direct Deposit Request
* Get your reimbursements faster and easier--direct to your checking or savings! - Additional Debit Card Request
* Complete if member wants a debit card for a spouse or dependent child - FLEX Employee Handout with the Debit Card
- FLEX Employee Handout without the Debit Card
- FLEX Employee Debit Card Merchant List
FLEX Debit Card
- Additional Debit Card Request
* Complete if member wants a debit card for a spouse or dependent child
HRA forms
- HRA Setup Sheet
- HRA Eligible Reimbursable Expenses
- HRA Reimbursement Request
* use when filing a manual claim - Direct Deposit Request
* Get your reimbursements faster and easier--direct to your checking or savings! - Additional Debit Card Request
* Complete if member wants a debit card for a spouse or dependent child - HRA Employee Debit Card Merchant List
COBRA forms
- COBRA Compliance Agreement
* Contractual agreement for new clients - COBRA Plan Information Sheet
* New client set up - COBRA Eligibility Form
* Notification for employee & dependent adds, terminations, and changes - COBRA Participant Information Form
* New client listing of current COBRA participants - Cobra Re-notification Form
* ARRA compliance
Links to Partners
EBS Contacts
Informative Videos
- Learn how to keep your Rx costs down, watch our Drug Smart Video.
How to Forms
Miscellaneous Forms
- EBS Enrollment Application form
- EBS Universal Change form
- Illinois Dependent Verification Form
- Iowa Dependent Verification Form
Partial Self Funded Forms
- Illinois Dependent Verification Form
- Iowa Dependent Verification Form
- Partial Self Funded Setup Sheet
Self Funded Forms
- Illinois Dependent Verification Form
- Iowa Dependent Verification Form
- Self Funded Medical Setup Sheet
- Self Funded Dental
- Self Funded Vision
Release Forms
Questionnaires
- Medical Questionnaires
* Please note - use print by page # for individual forms.
