Forms

Forms

You are welcome to download and print the current versions of these Manley Services forms. Just click on the links below.

All materials are in Adobe Acrobat PDF format. To open them, you must have Adobe Acrobat Reader installed on your computer. If you do not have this software, you can download it free from the Adobe Web site; click on this link and follow the instructions: Download Adobe Acrobat Reader

Authorization for EFT/Direct Deposit - for participants (to set up an account for reimbursement deposits via electronic funds transfer)	En Español
Employer Authorization for Recurring EFT (to set up recurring automatic funds transfers for plan premium payments)
Benny™ Card Receipt Submission Form (for Benny™ card users who would prefer to submit their Benny™ Card receipts immediately, in case verification is needed, rather than wait for a receipt request letter)
Benny™ Card Refund Submission Form (for Benny™ card users who need to refund their account for ineligible charges.)
COBRA Notification (to inform us when an employee becomes eligible for COBRA continuation coverage; to be completed by the employer)
COBRA Initial Notification (to inform newly enrolled employees that they and their covered dependents have COBRA rights if they have a qualifying event; to be completed by the employer)
EasyPay Enrollment Form For participants who have both a Manley plan and PacificSource health insurance
Electronic Enrollment Flier for New Groups or Renewals (instructions for preparing and e-mailing your group set up)
Examples of Eligible Health-Related Expenses (While not technically a form, this handout is useful in conjunction with the Benefit Analysis Worksheet.)
Flexible Spending Account Benefit Analysis Worksheet (a guide for calculating flexible spending allottments)	En Español
Premium Only Plan Service Agreement (for employers interested in the Premium Only Plan)
Request for Reimbursement from FSA or HRA (for use with the flexible spending account or health reimbursement arrangement)	En Español
Request for Reimbursement from Transportation Benefit (for use with the transportation benefit account)
FSA Summary Plan Description (general information regarding the FSA plan)	En Español
HRA Summary Plan Description (general information regarding the HRA plan)

If you have any trouble printing these forms, please e-mail the webmaster.

Educational materials for your employees

Please visit our Fliers & Brochures page located under Agents & Brokers. The materials are available as PDF files, which you may download and print. You may also add links on your company's intranet directly to the PDFs.