Employer Forms and Materials

These forms and materials are available for use by employers and agents. If you have questions about our products or how to complete a form, please contact us.

Brochures

Forms

  • Employer ACH Authorization Agreement
  • Authorize SelectAccount to charge your bank account through the Automated Clearinghouse (ACH) for SelectAccount claim payments.
  • FSA Plan Design Guide
  • Design a SelectAccount flexible spending account plan that fits your organization's goals.
  • Group Change Request Form
  • Use this form to indicate a change in group contact information with SelectAccount. This form must be completed by an authorized Group Contact.
  • HRA Enrollment Form
  • Submit enrollment information to SelectAccount for the participants in the HRA plan.
  • HRA Plan Design Guide
  • Design an HRA plan that fits your organization's goals.
  • HSA Contribution Form
  • Use when submitting an HSA contribution check to SelectAccount to indicate the contribution amounts for the HSA participants.
  • HSA Plan Design Guide
  • Design an HSA plan that fits your organization's goals.
  • Location Addendum
  • Use this form to indicate multiple locations along with a Plan Design Guide.
  • Premium-Only Plan Design Guide
  • Complete the Pretax Group Insurance Benefit Plan Design Guide to sign up for a SelectAccount Premium-Only plan and receive a welcome packet.
  • VEBA Contribution Form
  • Use when submitting a VEBA contribution check to SelectAccount to indicate the contribution amounts for the VEBA participants.
  • VEBA Enrollment Form
  • Submit enrollment information to SelectAccount for the participants in the VEBA plan.

Contact Us

If you have questions about our products or how to complete a form, please contact us. Our Client Advocates are available Monday-Friday, 8:00 a.m.-4:30 p.m. (Central Time).

Electronic Submission of Payroll/Enrollment

Did you know? You may send your enrollment or contribution files to us using a secure transfer method instead of email. We can create a login for you to transmit your files directly to our server using secure HTTPS or SFTP, both of which are recognized in the industry as strong encryption methods for transmitting data. We are pleased to offer this secure method of transfer to show our commitment to securing your data.

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