Forms

The following forms can be used to claim reimbursement from your existing pre-tax plan.

Please make sure to select the correct form for your type of plan.  If you are unsure, please contact us for forms specific to your plan.

Forms can be submitted via email, fax or mail (see below).

 

¨ Medical Reimbursement Claim Form

¨ Daycare Claim Form

¨ HRA (Health Reimbursement Arrangement) Claim Form

¨ Education Claim Form

¨ Transportation Claim Form

 

 

If you need to make a change to your plan, please use the following forms.  Please be sure to submit these forms to your payroll or HR person as well as to us.

¨ Name / Address / Phone Change Form

¨ Family Status Change Form (use to change Medical Reimbursement withholding)

 

ADMINISTRATIVE SERVICES, INC.

Specialists in Employee Benefits

Administrative Services, Inc.
Rochester Station
205 S Walnut
PO Box 590
Rochester IL  62563

 

Phone: 217-498-8450
Fax:  217-498-8481
E-mail:  cafe@asi-tpa.com

To contact us: