Forms

The list below has the most commonly used Cafeteria Forms. Just click on the name of the form and print it off on your printer.

Employee Brochure: The employee foldover brochure PBS provides for new employees.
Eligible Expenses: This is a general list of common medical expenses allowable under the Section 125 Cafeteria Plan.
Enrollment Spreadsheet: Used by the employer to annually set up the participant's accounts.
Claim Form: Used by participants to send in their receipts to PBS, Inc. for reimbursement of eligible expenses.
Enrollment Form with Employer Dollars: Used to enroll participants on an annual basis or for enrolling new employees.
Enrollment Form without Employer Dollars: Used to enroll participants on an annual basis or for enrolling new employees.
Change Form: Used by participants during the plan year to change their election if they experience an IRS-approved Family Status Change.
Termination/Layoff Form. Used by the employer to report terminations and layoffs to PBS, Inc.
Employee Worksheet: Used by participants to plan their expenses and estimate their tax savings from participating in the Cafeteria Plan.
EFT Authorization Form.
HRA EFT Authorization Form
Document Preparation Sheet

For assistance contact our Cafeteria Plan staff at cafeteria@profben.com.

Check back frequently because only the most current forms will be accepted.
Employee Brochures and Eligible Expenses are in a pdf format that can be conveniently emailed to your employees.
The Employee Worksheet can be used by employees to plan their expenses and estimate their tax savings.