Employee Cafeteria Plan Form Downloads
National Benefit Services, LLC forms

Sample Expenses - FSA/Cafeteria For medical, dental, vision reimbursement Samples of various items that are or are not eligible for reimbursement.

Claim Form - FSA/Cafeteria For medical, dental, vision and day care reimbursement Print and fill out, then fax or mail to NBS for reimbursement.

Claim Form - Transit For Transit and Parking reimbursement Print and fill out, then fax or mail to NBS for reimbursement.

Claim Form - HRA For employer funded HRA accounts (For HRA Plan Use Only) Print and fill out, then fax or mail to NBS for reimbursement.

Claim Form - Limited FSA (For HSA associated benefits only) For limited dental, vision, daycare and preventative care reimbursement. Print and fill out, then fax or mail to NBS for reimbursement.

Enrollment Form with Debit Card Employee Cafeteria Plan Enrollment During Open Enrollment for your company plan, print, fill in the required info and return to NBS.

Enrollment Form without Debit Card Employee Cafeteria Plan Enrollment During Open Enrollment for your company plan, print, fill in the required info and return to NBS.

Change of Status Employee Change of Status Form Birth, Death, Different Job, this form is for changing your 125 election.

Daycare Receipt Employee Dependent Care Claim This form must be submitted with your dependent care claim form.

Daycare Continual Reimbursement Employee Continual Reimbursement Form This form and worksheet will allow you to be continually reimbursed without having to turn in a claim form each time you send your child to daycare. Direct Deposit Request Employee Direct Deposit Form This form is used if you want your reimbursements directly deposited into your checking or savings account. Participant Web Account Instructions Employee Account Balance This will help get your cafeteria account balance online. Health Care Expenses Worksheet Employee This worksheet will help you figure out how much you will need to allow in you 125 plan. Orthodontic Payment Schedule Employee Ortho Form This form will allow you to plan your Orthodontic payments and have them automatically reimbursed. IRS Child & Dependent Form 2441 Employee IRS Form 2441 This form is used when filing yearly taxes, should be attached to schedule 1040. IRS Release of Exemption Form 8332 Employee Release of Exemption for Chid This form allows the parent Release of Claim to Exemption for Child of Divorced or Separated Parents, should be attached to the noncustodial parent’s return each year exemption is claimed.. Enrollment Packet Employee Enrollment packet only This packet is for employees who want to enroll in their company's cafeteria plan. HIPAA Privacy Notice HIPAA Information Some helpful information regarding HIPAA Law.