Resources for FSAs
This page provides Employer and participant resources, forms, and guides for Flexible Spending Accounts (FSA).
This page shows resources to help you administer your EMPOWER FSA. If you would like to view our Enrollment Resources page that has helpful information for enrollment, click the link below.
Table of Contents
Forms
Participant Forms
Change in Status/Qualifying Event Form
Required for mid-year changes to an FSA.
Direct Deposit Authorization Form
Add or change an existing bank account to receive reimbursements right to your bank account
FSA Enrollment Form
This is an enrollment form that you may distribute to your employees. This includes Health and Dependent Care FSAs.
FSA Enrollment Form (with Limited Purpose FSA)
Use this enrollment form if you have an FSA and Limited Purpose FSA
Forms
Employer Forms
Autopay Enrollment Form
Banking Setup Form
Use this form to set up your Employer bank account with EMPOWER.
FSA COBRA Form
Use this form to send to terminated Employees to elect COBRA.
Nondiscrimination Questionnaire
Form for Employers to submit information for nondiscrimination testing.
Payroll Frequency Change Form
Use this form to request mid-year payroll frequency changes
Enrollment Methods
Enrollment Spreadsheet
Use this link to download the enrollment spreadsheet to send you enrollments to EMPOWER.
EMPOWERConnect
EMPOWERConnect is an optional service that automatically integrates with your HRIS or Payroll system.
Instructional Guides
Participant Instructional Guides
Instructional Guides
Employer Instructional Guides
Employer Welcome Guides
Guides are available that explain how to administer your EMPOWER Plan.
You will receive guides when setting up a new plan and during open-enrollment. Ask your Account Administrator for additional information.
Employer Portal Quick Start Guide
Use this guide to learn how to use the Employer Online Portal.
PCORI Guide
Read this guide to determine if you are required to pay PCORI fees to the IRS.
