In an effort to make things easier for you, Savers Administrative Services has some common forms available for download. All forms are in Adobe Acrobat PDF format. If you do not have Acrobat Reader, you may download a free copy from Adobe Systems, Inc.

Claim Forms

FSA Medical / Healthcare Claim Form

FSA Dependent Care / Day Care Claim Form

Health Reimbursement Arrangement (HRA) Claim Form

Payroll

W4

NC4

Other Forms

Direct Deposit Authorization - to sign up for direct deposit of manual claim reimbursements

Flexible Spending Account Change of Status Form - to request a change in your FSA election when you have a qualifying event

FSA Medical / Healthcare New Enrollee Worksheet - to help you calculate your annual contribution amount

FSA Dependent Care / Day Care New Enrollee Worksheet - to help you calculate your annual contribution amount

Employee Participation Form - to sign up for your employer's FSA Plan

Informational Documents

IIAS Participating Merchants - list of merchants who will participate in the new IIAS approval system. Lear more about IIAS from our IIAS Announcement and FAQ document.

Instructions for Setting Up Your FSA Online Account - check your balance online, view transactions, and more

Eligible and Ineligible Flex Account Expenses - overview of items that may or may not be purchased with Flex account funds

"Remember SAVERS" - tips and hints regarding the use of your Flex account and your FSA debit card