FlexOptions Forms

The forms below pertain to the implementation and administration of the FlexOptions product:

Employer Initial Enrollment:

To get started, please provide CoPower Financial with a completed Intent to Enroll and the appropriate enrollment forms will be sent to you.

• CoPower Financial Intent to Enroll Form
• HCSO HRA Employer Application
• POP-Only Employer Application

Employee Enrollment Forms—Inforce Groups:

• CoPower Financial Employee Application
• CoPower Financial HSA Employee Application
• Employee HSA Contribution Form
• HCSO Employee Voluntary Waiver Form
• HCSO Employee Voluntary Waiver Form (Chinese)
• HCSO Employee Voluntary Waiver Form (Spanish)

Employer General Administration Forms:

• Employer Flex Credits Contribution Form
• Employer HSA Contribution Form
• Termination of Coverage & COBRA Continuation Form
• FlexOptions Information Change Form
• HSA Bank HSA Contribution Form (Prior Year)
• HSA Bank Excess Contribution Removal Form
• HCSO Expenditure Census Template—Groups with 20–49 employees
• HCSO Expediture Census Template—Groups with 50+ employees
• HCSO HRA Sample Year-to-Date Report
• HCSO HRA Sample Disbursement Register

Employee General Administration Forms:

• Employee Tax Savings & Contribution Worksheet
• HSA Contributions Change Form
• HFSA Mid-Year Election Change Request Form
• DCAP Mid-Year Election Change Request Form
• Direct Deposit Form

Claims Reimbursement and Transfer/Rollover Forms:

• HSA Transfer/Rollover Request Form
• HFSA/LHFSA/DCAP Reimbursement Form
• Transit Reimbursement Form
• HCSO HRA Overview with Direct Deposit & Claim Forms