Generic Forms

Generic Claims Reimbursement Form

Data Gathering Form

COBRA Event Form

Direct Deposit Form


Benefit Services Description

Benefit Services Summary


HSA Reference Manual 2018

HSA Reference Brochure for 2018

HSA Rollover Form

HSA Deposit Slip

HSA Request for Distribution

HSA Employer Data Gathering Form

HSA Account Information Change Form

HSA Custodial Agreement with Application

HSA Application & Beneficiary Form

HSA Fee Schedule & Interest Rate Table

Investment Options Guide

HSA and FSA Eligible Expenses are located in the FSA Store link below

FSA Eligible Expenses and Items

Model Forms for ACA

Notification to Employees for Employers without a Health Plan

Notification to Employees for Employers with a Health Plan

Employee Benefits Administration Services • 218 N. Broadway St., Ellsworth, WI 54011

715.273.0128 • 866.341.EBAS • (fax) 715.273.0147

© EBAS 2017