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Employee Benefit Systems

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  • 2009 FLEXsmart Card Account Login


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  • Summary of 125 Cafeteria Plan
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    •
    Employee 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.

  • 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 you want a debit card for a spouse or dependent child

  • Transportation and Parking Claim Form
  • Transportation Eligible Expenses
        * use when filing a transportation expense-related claim

  • Link to Wellmark Forms
        * access Wellmark's forms via this link



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    How to Forms

  • How to Read Your EOB
  • Mediweb User Guide


    • Release Forms

  • RQST to RLS EOB
  • Wellmark EOB Release Form

    • Informative Videos

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

    • EBS Contacts

  • Manager Contact list

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    Employee Benefit Systems
    214 North Main St.
    Burlington, Ia 52601
    Tel: 319.752.3200
    Toll Free: 800.373.1327
    Fax: 319.758.6271
    Email ContactUsEbs@ebs-tpa.com

    Member of Two Rivers Financial Group