Flexible Spending Account Forms
Employer Applications
Premium Only Plan Application
(174KB)
Reimbursement Account Flexible Benefits Employer Application
(462KB)
Reimbursement Account Flexible Benefits Employer Application including Flex Debit Card
(323KB)
COBRA Continuation Election for Medical Reimbursement Accounts
(148KB)
Health Reimbursement Account (HRA) Employer Application
(283KB)
Health Reimbursement Account Employer Application including Flex Debit Card
(339KB)
Enrollment Forms
Pre-Tax Premium Payments Mandatory Enrollment Form #H-8707
(98KB)
Pre-Tax Premium Payments Non-Mandatory #H-8711
(110KB)
Employee Reimbursement Account & Pre-Tax Premium Payment Mandatory Combination #H-8754
(122KB)
Employee Reimbursement Account & Pre-Tax Premium Payment Mandatory with Debit Card Authorization #H-8772
(238KB)
Employee Reimbursement Account & Pre-Tax Premium Payment Non-Mandatory Combination #H-8757
(122KB)
Employee Reimbursement Account & Non-Mandatory Pre-Tax Premium Payment with Debit Card Authorization #H-8774
(250KB)
Pre-Tax Premium Payments and Employee Reimbursement Accounts Change Form #H-8764
(135KB)
Health Reimbursement Account #H-8767
(222KB)
Health Reimbursement Account with Debit Card Authorization #H-8382
(143KB)
Administrative Forms for Employees
View and download
employee flex forms
Educational Materials
Order Blue Priority Flex
SM
member education materials on the
Employer Toolkit
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Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association doing business in Iowa and South Dakota.
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