Forms for Employers

Simply click on the name of the form that you wish to download.

• Accident Questionnaire
• Appointment of Authorized Representative
• Automatic Dependent Care Reimbursement Claim Form
• Coordination of Benefits Questionnaire
• Credit Authorization Form
• Dependent Care Reimbursement Claim Form
• Flexible Spending Claim Form
• HRA Reimbursement Claim Form
• Proof of Short Term Disability
• Request for Creditable Coverage Certificate
• Request for Review of Benefit Denial
• Transportation Account Claim Form
• Medicare Part D - Creditable
• Medicare Part D - Non Creditable
• Privacy Notice - 2013

For more information, click here to contact EBSO.