Participant Forms

These materials are for flexible benefits participants who are NOT SEGIP or Minnesota State employees

(SEGIP and Minnesota State employees, please find your materials here: SEGIP materialsMinnesota State Materials.)

Enrollment Forms

Flexible Benefits Enrollment

Transit Enrollment

Reimbursement FORMS

Reimbursement Request

Transit Account Reimbursement

Change/Termination Forms

Flex Change / Termination Form

Transit Change Form
If you are an employee/participant with Hennepin Healthcare Systems, do not use this form.   Login to employee self-service and click on Employee Benefits tile.  Choose life events/all other life events/transportation FSA changes.  Enter the date and complete the process or contact your enrollment vendor at 877-558-1177.

Request Change in HSA Participation Form

BANK Forms

Lost Check Affidavit

Direct Deposit

Repayment Authorization Form

Cobra Refund Authorization Form

730 2nd Avenue South, Suite 400
730 Building
Minneapolis, MN 55402-2446

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