EMPOWER We are here for you! Advanced Flex Plan Administration with the Human Touch Resources for all Benefits This page provides Employer and participant resources, forms, and guides for all Benefits. This page shows resources for all benefits. If you wish to view only the resources for your Plan, click the appropriate button below. Show me FSA Resources Only Show me HSA Resources Only Show me HRA Resources Only Table of Contents Forms Participant Forms Name Description Plan English Spanish Change in Status/Qualifying Event Form Required for mid-year changes to an FSA. FSA Download English Direct Deposit Authorization Form Add or change an existing bank account to receive reimbursements right to your bank account All Plans Download English FSA Claim Form Use this form to submit an FSA claim. FSA Download English FSA Enrollment Form This is an enrollment form that you may distribute to your employees. This includes Health and Dependent Care FSAs. FSA Download English FSA Enrollment Form (with Limited Purpose FSA) Use this enrollment form if you have an FSA and Limited Purpose FSA FSA and LPFSA Download English HRA Claim Form Use this form to submit an HRA claim. HRA Download English HSA Beneficiary Form Use this form to add or change an HSA beneficiary. HSA Download English HSA Claim Form Use this form to submit an HSA claim. HSA Download English HSA Contribution Form Use this form to make an HSA contribution outside of your Employer’s payroll. HSA Download English HSA Contribution Change Form Use this form to make a change to your HSA contributions. HSA Download English HSA Custodial Agreement All HSA participants must either accept the HSA terms on the Online Portal or sign this form and return the last page to EMPOWER. HSA Download English HSA Enrollment Form This is an enrollment form that you may distribute to your employees. HSA Download English HSA Transfer Form Form to transfer the balance from another account to the participant’s current EMPOWER HSA account. HSA Download English Employer Forms Name Description Plan English Spanish Banking Setup Form Use this form to set up your Employer bank account with EMPOWER. All Plans Download English FSA COBRA Form Use this form to send to terminated Employees to elect COBRA. All Plans Download English Nondiscrimination Questionnaire Form for Employers to submit information for nondiscrimination testing. All Plans Download English Enrollment Methods Name Description Plan English Spanish Enrollment Spreadsheet Use this link to download the enrollment spreadsheet to send you enrollments to EMPOWER. All Plans Link EMPOWERConnect EMPOWERConnect is an optional service that automatically integrates with your HRIS or Payroll system. All Plans Link Instructional Guides Participant Instructional Guides Name Description Plan English Spanish FSA Welcome Guide (PDF) Comprehensive guide to using the EMPOWER FSA. FSA Download English Coming Soon FSA Welcome Guide (Online) Comprehensive guide to using the EMPOWER FSA. FSA Link Coming Soon HRA Welcome Guide (Online) Comprehensive guide to using the EMPOWER FSA. HRA Download English Coming Soon HRA Plan Fact Sheet A single page handout that contains specific details about your Plan. HRA Your Account Manager will email this to the Employer before open enrollment starts. HSA Welcome Guide (PDF) PDF guide that details the HSA Plan for new participants. HSA Download English Coming Soon HSA Welcome Guide (Online) Comprehensive guide to using the EMPOWER HSA. HSA Link Coming Soon Participant Portal Quick Start Guide Learn how to use the Online Portal (FSA and HRA). FSA, HRA Link Coming Soon Participant Portal Quick Start Guide Learn how to use the Online Portal (HSA). HSA Link Coming Soon Employer Instructional Guides Name Description Plan English Employer Welcome Guides Guides are available that explain how to administer your EMPOWER Plan. All Plans 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. All Plans Download English PCORI Guide Read this guide to determine if you are required to pay PCORI fees to the IRS. FSA, HRA Link Additional Resources Participant Resources Name Description Plan English Spanish Eligible Items List of eligible items for all Plans. All Plans Download English Coming Soon HSA Investment Options List of HSA Investment Options HSA Download English