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Forms

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Get things done faster online.

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COBRA
  • COBRA Refund Request FormMore info
    • Please use this form to authorize an ACH refund to your account.
  • PHI Authorization/Revocation FormMore info
  • COBRA BrochureMore info
    • Answers the many questions you may have regarding your COBRA benefits.
See all COBRA
Commuter Benefit Plan
  • Claim FormMore info
    • To request reimbursement of eligible expenses.
  • Enrollment/Change Form CBPMore info
    • To enroll or report changes in your CBP.
  • Direct Deposit Authorization FormMore info
    • To set up new authorization of reimbursements to be deposited directly into your bank account or to change current direct deposit information.
See all Commuter Benefit Plan
Flexible Spending Account
  • Claim FormMore info
    • To request reimbursement of eligible expenses.
  • PHI Authorization/Revocation FormMore info
  • Medical FSA Expense WorksheetMore info
    • Extensive list of IRC section 125 eligible expenses to help you plan your Medical FSA election.
  • Opt Out Form FSAMore info
    • To decline participation in the tax-free benefit.
  • Enrollment/Change Form FSAMore info
    • To enroll in your FSA Plan or to report changes in status, address, elections, etc.
  • Dependent Care ReceiptMore info
    • For your dependent care provider to use as a receipt for eligible dependent care services provided to you.
  • Dependent Care Expense WorksheetMore info
    • Extensive list of IRC section 125 eligible expenses to help you plan your Dependent Care FSA election.
  • Over-The-Counter (OTC) ChartMore info
    • Sample chart of OTC items that may be eligible from your HRA or FSA. You should check your plan’s documentation to see if OTC items are eligible under your plan.
  • Mileage Expense Certification FormMore info
    • To provide supporting documentation when claiming mileage for eligible services from your pre-tax account.
  • Direct Deposit Authorization FormMore info
    • To set up new authorization of reimbursements to be deposited directly into your bank account or to change current direct deposit information.
  • Certification of Medical Necessity FormMore info
    • To use for medical services/items that require additional documentation from a licensed health care provider.
See all Flexible Spending Account
Health Reimbursement Account
  • HRA Recurring Premium Attestation FormMore info
  • Claim FormMore info
    • To request reimbursement of eligible expenses.
  • PHI Authorization/Revocation FormMore info
  • Over-The-Counter (OTC) ChartMore info
    • Sample chart of OTC items that may be eligible from your HRA or FSA. You should check your plan’s documentation to see if OTC items are eligible under your plan.
  • Opt Out FormMore info
    • To opt out of participating in your employer sponsored HRA.
  • Mileage Expense Certification FormMore info
    • To provide supporting documentation when claiming mileage for eligible services from your pre-tax account.
  • Medical Expense WorksheetMore info
    • Extensive list of medical expenses that may be eligible under your HRA Plan.
  • Enrollment/Change Form HRAMore info
    • To enroll or report changes in your HRA Plan.
  • Direct Deposit Authorization FormMore info
    • To set up new authorization of reimbursements to be deposited directly into your bank account or to change current direct deposit information.
  • Certification of Medical Necessity FormMore info
    • To use for medical services/items that require additional documentation from a licensed health care provider.
See all Health Reimbursement Account
Health Savings Account
  • Withdrawal Request Form (UMB)More info
    • Request a withdrawal from your UMB Health Savings Account
  • Name Change Form (UMB)More info
    • Form to change the name associated with your Health Savings Account.
  • Transfer Form (UMB)More info
    • Form for transferring your account to UMB from another trustee
  • Beneficiary Form (UMB)More info
    • Designate the beneficiary for your Health Savings Account.
  • Over-The-Counter (OTC) ChartMore info
    • Sample chart of OTC items that may be eligible from your HSA.
  • Medical Necessity Directive Form HSAMore info
    • To use for personal documentation of medical services/items, such as over-the-counter medicines and drugs, that require additional documentation from a licensed health care provider. (Retain for your records.)
  • Enrollment/Change Form HSAMore info
    • To enroll or make changes in your HSA program.
  • Direct Deposit FormMore info
    • This form allows an employer, or other organization, to establish direct deposit into your HSA.
  • Change of Contact Information (UMB)More info
    • This form can be used to update your name, email address, telephone number, and home address information for your HSA to UMB Financial Corporation.
See all Health Savings Account

Benefit Resource, LLC

Simplifying the complexity of benefits for maximum savings and peace of mind.



Contact Information

245 Kenneth Drive
Rochester NY 14623-4277

Benefit Resource, LLC
PO BOX 642
Willow Grove, PA 19090

EMPLOYEES: (800) 473-9595
EMPLOYERS: (866) 996-5200

For Employees

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The Beniversal and eTRAC Prepaid Mastercards are issued by The Bancorp Bank pursuant to license by Mastercard International Incorporated. Mastercard is a registered
trademark, and the circles design is a trademark of, Mastercard International Incorporated. The Beniversal and eTRAC cards are accepted at qualified merchants accepting Debit
Mastercard. The Bancorp Bank; Member FDIC.

HSA Custodial Services are provided by a separate financial institution. See your HSA Account Agreement for specific account terms.

©2022 BRI | Benefit Resource All Rights Reserved.Privacy Policy|Terms of Use|Accessibility|Website developed by Mason Digital

BRI Logo
  • Employees
        • Plans & Services

        • Flexible Spending Account
        • Health Savings Account
        • Health Reimbursement Account
        • Commuter Benefit Plan
        • COBRA Benefits
        • Resources

        • Beniversal Card
        • BRIWEB
        • BRI Alerts
        • BRIMOBILE
        • Forms
        • Español
        • Employee Logins

          BRIWeb Login
          Trouble Logging In?

          COBRA Login
  • Employers
        • Plans & Services

        • Flexible Spending Account
        • Health Savings Account
        • Health Reimbursement Account
        • HRA VEBA Account
        • Commuter Benefit Plans
        • COBRA Administration
        • Direct Billing
        • Specialty Accounts
        • Resources

        • Open Enrollment
        • OE Email Request
        • Employer Login
        • Design Your Plan

          We would love to chat with you about your current benefits offerings and best practices that may save you and your employees even more.

          Submit Your RFP Now

  • Resources
        • Employee Resources

        • All Employee Resources
        • Open Enrollment
        • Commuter Resource Center
        • Employer Resources

        • All Employer Resources
        • Open Enrollment
        • OE Email Request Form
        • More Links

        • Forms
        • Frequently Asked Questions
        • COVID-19 Resources
        • Español
        • Resource Center

          Search through our interactive database of videos, flyers, tutorials, and other tools to help maximize your BRI experience.

          View All Resources

  • Blog
  • About
        • Why Choose BRI?

          BRI combines expertise and excellence to provide premier ongoing support to employers and participants, backed by experts and technology you can trust.

        • Technology

          Why BRI - Technology

          Technology

        • Account Expertise

          Why BRI - Account Expertise

          Account Expertise

        • Service Culture

          Why BRI - Service Culture

          Service Culture

        • Learn More
        • Company

        • Leadership
        • Press Room
        • Partnerships
        • Recognition
        • Contact Us
        • Career Opportunities

          BRI is consistently listed in the Rochester Top 100 Companies! We offer growth opportunities and competitive benefits. Join a great place to work!

          Learn More

  • Careers
    • Employees
    • Employers
    • COBRA
Get A Proposal

© 2022 BRI | Benefit Resource

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