Combined Services LLC Downloads

Questions, comments or need a form that's not listed? Please contact Combined Services LLC at 1 888 227-9745, Monday through Friday 8:00 a.m. to 4:30 p.m. (EST).

Form Downloads

To download up to date forms, please click on the links below of the desired company's website. Viewing, filling in, printing and saving forms require Adobe Acrobat Reader.

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Flexible Benefits - Form Downloads

Download	Form	Description
	Flexible Benefit Plan Enrollment Form	An enrollment form for Medical and Dependent Care Reimbursement Accounts needs to be completed each plan year and upon the change of election with a qualifying event. A pdf of these forms will be provided to you with your Employer's name upon enrollment with Combined Services LLC. Post the pdf on your intranet site or keep it on file with Human Resources for easy access.
	Direct Deposit Authorization Form	This is an authorization form to have Combined Services LLC (CSLLC) initiate direct deposits to a Medical and/or Dependent Care Reimbursement Participant's checking or savings accounts.
	Premium Conversion Refusal Form	Employees who elect to waive participation in the Premium Conversion Plan must complete this form. Your company's Premium Conversion Refusal form is located at the end of your Plan Document.
	ACH/Direct Deposit & Debit Card mbi Banking Authorization	The ACH/Direct Deposit Authorization form allows Combined Services LLC automatically debit the employer's account for claims processed each week. This form and the Debit Card mbi Banking Authorization, which automatically debits the employer's account for all debit card transactions processed daily, must both be completed by the employer in order to offer debit cards to participants. These forms can also be used to communicate changes regarding the account.
	Add/Change/Termination Form	This form is used to notify Combined Services of qualifying event changes to an employee's Flexible Benefits Plan, including termination of employment. Once this form is completed and signed by the employee and employer, it should be mailed or faxed to Combined Services LLC.
	List of Eligible Expenses	This is list of eligible expenses for the medical reimbursement plan. It is not intended to be complete, however, it illustrates the type of health care expenses that can be claimed as part of the Plan. (source: IRS Publication 502)

Flexible Benefits - Samples Downloads

Download	Form	Description
	Welcome Letter	This letter is generated by Combined Services' Flexible Benefits Department once a company is enrolled. A sample of welcome letter has been set as an attachment to this document.
	Flexible Benefits Reimbursement Request Form	This form is for both Medical and/or Dependent Care Reimbursement Claims. Instructions are listed on the second page of of this form and it can be filled out online and printed with Adobe Acrobat Reader.
	COBRA Notification Letter for Continuation of Coverage	Medical Reimbursement Accounts are sometimes subject to COBRA. A sample of this letter has been set as an attachment on this document. Please contact Combined Services LLC if you have questions regarding COBRA Notification.

Literature Downloads

Download	Form	Description
	Flexible Spending Accounts Brochure	This brochure reviews the concept of reimbursement accounts for employees and should be distributed before enrollment. Once opened, the document can be printed, however, this document is not an 8½ x 11 booklet. (Please contact Combined Services LLC for a booklet size copy) Please Note: The same information contained in this brochure can also be found here.
	Debit Card Brochure	If your employer has elected to use debit cards, this is an informative brochure on how it works.
	Important Information for Flex Debit Card Participants (contact Combined Services LLC for sample)	This worksheet describes Combined Services LLC's process for notifying the employee of a debit card purchase for other than the employer co-pay of prescription drugs or office visits.
	Over-the-Counter Examples	This list provides examples of eligible over-the-counter medications for the Medical Reimbursement Account.

Non-Discrimination Tests

Discrimination as to Contributions and Benefits:

A Flexible Benefits Plan may not discriminate in favor of "highly compensated participants" as to contributions and benefits. A plan must give each participant an equal opportunity to select nontaxable benefits, and the actual selection of nontaxable benefits must not be discriminatory. A plan cannot allow more benefits to be available to highly compensated participants than to other participants. However, the utilization of the nontaxable benefits by highly compensated participants does not need to be identical to the utilization by other participants. If you would like Combined Services to complete your employer's non-discrimination testing, complete the following census forms and submit them to Combined Services' Flexible Benefits Department.

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This worksheet describes the format and information needed for a complete census.

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This worksheet outlines the business information needed to prepare the non-discrimination testing.

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Concentration Test
(contact Combined Services LLC for test)

The concentration test under Section 125 provides that no more than 25% of the statutory nontaxable benefits under the plan may be provided to "key employees". Key employees are defined in Code Section 426(I)(1) as:

1.	Employees who own more than 5% of the company;
2.	Employees who own more than 1% of the company and whose compensation exceeds $150,000;
3.	Any officer with compensation greater than 50% of the defined benefit dollar limit under Section 415 ($140,000 as indexed for 2006; this amount is indexed for inflation in increments of $5,000).

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Medical Reimbursement Account Eligibility Test
(contact Combined Services LLC for test)

To satisfy the nondiscriminatory eligibility requirement set forth in Code Section 105(h), a plan must satisfy as least one of the alternative tests: The plan must benefit 70% of all employees. 70% of all employees must be eligible to participate in the plan, and the plan must benefit 80% of those employees who are eligible.Because this is an eligibility test, Combined Services interprets "benefits" to mean "availability" not "utilization" of the Medical Reimbursement Account.

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Code Section 129- Dependent Care 55% Average Benefits Test
(contact Combined Services LLC for test)

The average benefits provided to non-highly compensated employees must be at least 55% of the average benefits provided to highly compensated employees (HCE). A highly compensated employee (HCE) is an employee who: is a 5% owner, or

received compensation for the preceding year in excess of $100,000 (in 2006 as indexed) from the employer and if the employer elects the application of this clause for the preceding year was in the "Top-Paid group" for that year.

Contact Us

The laws regarding Flexible Benefits can be complex. This online guide is only meant to be used as an overview to administering those benefits. If you have specific questions that are not answered here, you should refer to your Company's Plan Document or Summary Plan Description for more details. You should also feel free to contact a Representative at Combined Services LLC if you need assistance.

Phone:
1 603 227-2040

Toll-Free:
1 888 227-9745 ext. 2040

Email:
Flexible Benefits Department