CBA Benefit Services

Forms

The forms below are generic for general use. We customize most forms for our clients. Please contact us for your specific requirements.

Medical

Anthem – Enrollment Form
Medical Mutual – Enrollment Form
Medical Mutual – Student Certification Form
Starmark Employee Enrollment Form

Dental

Dental Enrollment Form
Dental Claim Form

COBRA

COBRA Reporting Form
COBRA Sample DOL Letter

FSA

FSA Employee Claim Reimbursement Form
FSA Eligible Expenses

HSA

HSA Eligible Expenses
HSA Huntington Fund Re-Designation Form
HSA Huntington Reimbursement Form
Wells Fargo Mistaken Distribution Form
Wells Fargo Direct Reimbursement Form

HRA

HRA Employee Reimbursement Form

Life

AUL Group Enrollment Form
AUL Combo Group Enrollment Form
Preliminary Application for Life Conversion
Portability of Voluntary Life Form

Rx

MEDCO Claim Form

**All forms listed above are in PDF format. If you do not have Adobe Reader, you may download a free copy by clicking on the image below.