FSA Forms & Documents

BELOW ARE SAMPLE FORMS WITH EXPLANATIONS FOR THEIR USE AND A LINK FOR DOWNLOADS.

 

Flexible Spending Accounts Brochure

 

Explains what Flexible Spending Accounts are,

the benefits of participation, such as tax savings

and provides a listing of qualified expenses.

 

Download this brochure with this link.

 

 


Online Access Instructions

 

 Explains how to set up online access to verify balances,

review transactions and follow up on reimbursements.

 

Download this form with this link.

 

 

 


Medical FSA Reimbursement Form

 

Use this form to submit reimbursements for qualified Healthcare

expenses when you did not or could not use the Alliance Flex

Card.

 

Download this form with this link.

 

 

 


Medical FSA Direct Deposit Form

 

Use this form to direct Alliance Insurance Group to direct deposit

your reimbursements from manual (non-Flex Card) transactions

directly with your bank. This form is typically used in conjunction

with the Reimbursement Form above.

 

Download this form with this link.

 


Dependent Care FSA Reimbursement Form

 

Use this form to submit reimbursements for qualified Dependent

Care expenses when you did not or could not use your Alliance

Flex Card.

 

Download this form with this link.

 

 


Dependent Care FSA Direct Deposit Form

 

Use this form to direct Alliance Insurance Group to direct deposit

your reimbursements from manual (non-Flex Card) transactions

directly with your bank. This form is typically used in conjunction

with the Reimbursement Form above.

 

Download this form with this link.