Forms

Employee Forms
Salary Reduction Agreement Form is used to collect FSA election information for new hires and at re-enrollment.
Employee Direct Deposit Form is to gather/update employee banking information so that Superior State can facilitate directly depositing reimbursement(s) from FSA's, HRA's, and MERP's into employee's account.
Claim Form Form is used by employee to submit claims for their FSA, HRA, or MERP account to Superior State for processing. Form is typically the 1st page of the fax, email, or mailed claim that is sent. Information for fax, email, and mail is at the bottom of the form.
Eligible Expense Listing Reference sheet showing typically allowed expenses under an FSA or HRA program. HRA programs should be cautious in distributing this form if the eligible items are narrowed to certain types of expenses such as deductible only.
FSA FAQ A useful handout to new employees providing answers to the most typical questions regarding reimbursement plans.
Employee Debit Card App If you offer debit cards as a payment method for your FSA or HRA, this is the form that is required to be completed by each participant to have a card issued.
Online Access Instructions Form explains the process for plan participants to sign up for online access to their benefits. Will require you to write in your "employer code". If you don't recall this 8 digit number, please contact us.
$500 FSA Carryover Info Form explains the benefits of the recent regulation changes to FSAs that will allow for a carryover of up to Five Hundred Dollars of unspent funds for use in the next year.
Transit Plan Forms
Transit Enrollment Form Used to enroll in transit and parking benefits for a Section 132 Reimbursement Plan.
Transit Claim Form Used to file claims for transit and parking benefits when participating in a Section 132 Reimbursement Plan.

Employer Forms
Information on Checks/Direct Deposit Information on how we can provide payment services for your plan, including an overview of the processes involved.
Sign Up / Modify Payment Services Complete this form to provide/update the banking information we will use when generating reimbursement via check or direct deposit to your employee participants.
Information on Debit Cards Information on how Debit Cards can be added as a method of payment to your FSA and/or HRA accounts. Overview will discuss pro's and con's of the program.
Sign Up / Modify Debit Cards Complete this form to provide/update the banking information our Debit Card issuer will use when generating replenishment requests to fund your Debit Card Settlement Account.
HSA Forms
HSA Claim Form Claim form can be used by account holders to submit expenses for review and certification and/or to request the withdrawal of funds from their HSA.
HSA Deposit Slip Form is used by account holders to mail in a deposit to their HSA.
HSA Account Rollover Form Form is used by existing HSA account holders to facilitate a transfer of funds from their previous HSA custodion to their new HSAToday account.
HSA Change Form Form is used by account holders to communicate information changes such as beneficiary changes, address changes, bank changes, etc...