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Broker Services and Forms

Forms updated May 2009


FLEXsmart Forms

These forms should be printed, filled out & signed.
Then fax or mail per instructions on the individual forms.
  • 125 Plan Setup Sheet
  • 125 POP Setup Sheet
  • HRA Setup Sheet


  • FLEXsmart Worksheet
        * To assist you with computing your annual enrollment
  • Cafeteria Plan Enrollment Form
        * For enrollments and re-enrollments
  • FLEXsmart Enrollment Change Form
        * New baby or other life changing events? - Please let us know!
  • Cafeteria Reimbursement Request Form
  • Flex Reimbursement Form    
    * use when filing a manual claim
  • FLEXsmart Eligible Reimbursable Expenses
  • HRA Eligible Reimbursable Expenses
        * Listing of eligible reimbursable expenses for Medical Spending
          Account, HRA's, and Dependent Care Accounts

  • Direct Deposit Form
        * Have your reimbursements faster and easier--direct to your checking or savings!
  • Additional Debit Card Request Form
        * Complete if member wants a debit card for a spouse or dependent child
  • FLEXsmart Handout with the Debit Card
  • FLEXsmart Handout without the Debit Card

  • FLEXsmart Debit Card Merchant List
        * When you get to the website, click on IIAS Merchant List under Publications on the left hand side of the page.

    COBRA forms

  • COBRA Compliance Agreement
  • COBRA Plan Information Sheet
  • COBRA Eligibility Form
  • COBRA Participant Information Form
  • Cobra Re-notification Form


    • Links to Partners

  • VSP homepage


    • EBS Contacts

  • Manager Contact list

    • Informative Videos

  • Learn how to keep your Rx costs down,
    watch our Drug Smart Video.
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    How to Forms

  • How to Read Your EOB
  • Mediweb User Guide
  • Standardized Spreadsheet for Enrollment import


  • EBS Enrollment Application form

  • EBS Universal Change form


    • Partial Self Funded Forms

  • Partial Self Funded Setup Sheet


    • Self Funded Forms

  • Self Funded Medical Setup Sheet
  • Self Funded Dental
  • Self Funded Vision

    Release Forms

  • RQST to RLS EOB
  • Wellmark EOB Release Form
  • Wellmark Customized Options & Services Form


    • Questionnaires

  • Medical Questionnaires
        * Please note - use print by page # for individual forms.
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