Employer Reimbursement Accounts Enrollment Form 2026

1. Click ‘Get Form’ to open the Reimbursement Accounts Enrollment Form in our editor.
2. Begin by filling out the Employer Use Only section, including your Employer ID Number and selecting whether this is a re-enrollment, new enrollment, or change.
3. In Section A, Personal Information, clearly print your Employer Name, Employee First Name, Middle Initial, Last Name, Social Security Number, Street Address, City, State, ZIP Code, Email, Date of Birth, and Date of Hire.
4. Move to Section B for Election Information. Check the box indicating whether you wish to participate in the Benefit Choices offered. Fill in the amounts for each benefit choice as required.
5. If applicable, complete Section C for Pre-Authorization for Direct Deposit by providing your bank details and attaching a voided check or savings deposit slip.
6. Finally, sign and date the form at the bottom to confirm your understanding of the terms outlined.

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