Employer Forms & Resources

Download and print commonly used forms. All forms are in PDF format. Download Acrobat Reader.

FORM: DESCRIPTION
Cancel Spouse or Dependent Coverage: This form notifies us to cancel existing coverage for a spouse or dependent.
Certification of Dependent Eligibility: When children reach college age, many of them can remain on a parent's coverage if they are enrolled as full-time students. Use this form to verify your student’s enrollment status.
Electronic Funds Transfer Authorization: Use this form to give BCBSWY authorization to withdraw premium funds from your bank automatically.
Medical Claim Form: Use this form to file a claim for medical services, such as office visits, physical therapy, laboratory services and radiology services such as X-rays.
Transaction Transmittal: Use this form to notify us of a name or address change, or to cancel, transfer or reinstate an employee’s coverage.

FORM: DESCRIPTION
FlexShare Brochure & Applications: Learn about and apply for FlexShare Benefits.
Premium Only Plan (POP): Enroll an employee in a Premium Only Plan.
Flexible Spending Account (FSA): Enroll an employee in a Flexible Spending Account.
Flexible Spending Account (FSA) & Premium Only Plan (POP): Enroll an employee in a Flexible Spending Account and a Premium Only Plan.
Health Reimbursement Arrangement (HRA) - Single Rate: Enroll an employee in a Health Reimbursement Arrangement with one level of contribution.
Health Reimbursement Arrangement (HRA) & Premium Only Plan (POP): Enroll an employee in a Health Reimbursement Arrangement and a Premium Only Plan.
Electronic Funds Transfer (EFT): Authorize BCBSWY to automatically make bank transfers for FlexShare Benefit funds.

FORM: DESCRIPTION
Who can participate?: Find eligibility for participation in a POP, FSA or HRA.
Change in Status Matrix for FSA: Explains qualifying events that allow participants to change an election for FSA healthcare or dependent care.
Expenses that Qualify for FSA Reimbursement: Common expenses that qualify for reimbursement.
Request for Reimbursement: Complete this form to file a FSA healthcare, dependent care or HRA claim.