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Employer Forms & Resources

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

Employer Forms

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.

FlexShare Forms

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.

FlexShare Resources

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.

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