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

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

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