Forms

Forms and Other Information

You are welcome to download and print the current versions of these Manley Services documents. Just click on the links below. Additional fliers and brochures are available under Agents & Brokers.

Employee Forms
Request for Reimbursement from FSA or HRA	En Español
Request for Reimbursement from Transportation Benefit
Direct Deposit Setup	En Español
Letter of Medical Necessity
Benny™ Card Receipt Submission Form
Benny™ Card Refund Submission Form
EasyPay Enrollment Form	En Español

Employer Forms
Premium Only Plan Service Agreement
HRA Summary Plan Description
FSA Summary Plan Description	En Español

Misc. Forms and Information
Examples of Eligible Expenses (updated 6/11)	En Español
Flexible Spending Account Allottment Worksheet	En Español (Updated 2/15/11)
Benny™ Card flier	En Español (New)
OTC Changes flier / OTC FAQ	En Español (Flier - new)
EasyPay information	En Español
FAQ about the Grace Period	En Español
OB Guidelines	En Español
Ortho Guidelines	En Español

If you have any trouble printing these forms, please e-mail the Webmaster. Please include your name and company name and indicate whether you are a participant or employer.