2021 Flexible Benefits Change in Participation
Use if you have a qualifying life event or are reinstating your MDEA/DCEA upon returning to work from a leave.
2021 SOM Transit Change Form
Use for mid-year enrollment or changes, or to reinstate your PKEA and/or BVEA upon returning to work from a leave.
2021 Change Form to Limited MDEA or HRA
Use if you and/or your spouse will be contributing to an HSA for the upcoming plan year and need to change your general-purpose MDEA to a Limited Purpose account.
2021 MDEA DCEA HRA Reimbursement Request
Use to request reimbursement from your MDEA/DCEA or State HRA plans
2021 Transit Reimbursement Form
Use to request reimbursement from your PKEA or BVEA State plans.
2021 MDEA DCEA Enrollment Form
Use if you are a new hire or newly eligible employee who is enrolling for the first time.
2021 Transit Enrollment Form
Use if you are a new hire or newly eligible employee who is enrolling for the first time. If you are paying for your parking and/or bus pass expenses directly through your agency, do not use this form to enroll.
Use to set up your reimbursements as direct deposit.
Lost Check Affidavit Form
Use if you lost a reimbursement check and need to request a replacement.
Repayment Authorization Form
Use to repay part of a debit card transaction