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.

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

Direct Deposit Authorization Form

Add or change an existing bank account to receive reimbursements right to your bank account

All Plans

FSA Claim Form

Use this form to submit an FSA claim.

FSA

FSA Enrollment Form

This is an enrollment form that you may distribute to your employees. This includes Health and Dependent Care FSAs.

FSA

FSA Enrollment Form (with Limited Purpose FSA)

Use this enrollment form if you have an FSA and Limited Purpose FSA

FSA and LPFSA

HRA Claim Form

Use this form to submit an HRA claim.

HRA

HSA Beneficiary Form

Use this form to add or change an HSA beneficiary.

HSA

HSA Claim Form

Use this form to submit an HSA claim.

HSA

HSA Contribution Form

Use this form to make an HSA contribution outside of your Employer’s payroll.

HSA

HSA Contribution Change Form

Use this form to make a change to your HSA contributions.

HSA

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

HSA Enrollment Form

This is an enrollment form that you may distribute to your employees.

HSA

HSA Transfer Form

Form to transfer the balance from another account to the participant’s current EMPOWER HSA account.

HSA

Employer Forms

Name

Description

Plan

English

Spanish

Banking Setup Form

Use this form to set up your Employer bank account with EMPOWER.

All Plans

FSA COBRA Form

Use this form to send to terminated Employees to elect COBRA.

All Plans

Nondiscrimination Questionnaire

Form for Employers to submit information for nondiscrimination testing.

All Plans

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

EMPOWERConnect

EMPOWERConnect is an optional service that automatically integrates with your HRIS or Payroll system.

All Plans

Instructional Guides

Participant Instructional Guides

Name

Description

Plan

English

Spanish

FSA Welcome Guide (PDF)

Comprehensive guide to using the EMPOWER FSA.

FSA

Coming Soon

FSA Welcome Guide (Online)

Comprehensive guide to using the EMPOWER FSA.

FSA

Coming Soon

HRA Welcome Guide (Online)

Comprehensive guide to using the EMPOWER FSA.

HRA

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

Coming Soon

HSA Welcome Guide (Online)

Comprehensive guide to using the EMPOWER HSA.

HSA

Coming Soon

Participant Portal Quick Start Guide

Learn how to use the Online Portal (FSA and HRA).

FSA, HRA

Coming Soon

Participant Portal Quick Start Guide

Learn how to use the Online Portal (HSA).

HSA

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

PCORI Guide

Read this guide to determine if you are required to pay PCORI fees to the IRS.

FSA, HRA

Additional Resources

Participant Resources

Name

Description

Plan

English

Spanish

Eligible Items

List of eligible items for all Plans.

All Plans

Coming Soon

HSA Investment Options

List of HSA Investment Options

HSA

EMPOWER Participant Mobile App Download

If you have an FSA, HRA, or HSA with EMPOWER, we encourage you to download the Mobile App to manage your benefits on the go!

Apple iOS Devices

Google Android Devices

EMPOWER LOGIN

I am a Participant

I am an Employer

Click the above link if you are a participant who has an FSA, HSA, or HRA with EMPOWER.

Click the above link if you are an Employer or Consultant. 

Download Forms

Click one of the links below to view the available forms.

I am a Participant

Click the above link if you are a participant who has an FSA, HSA, or HRA with EMPOWER.

I am an Employer

Click the above link if you are an Employer or Consultant.