Flexible Benefits Forms

Flexible Benefits Enrollment Form 2018-2019

Any employee who is eligible to participate in the employer's medical plan is eligible to participate in the Christian Schools International Flexible Benefit Plan Health FSA.  An employee must be must be 50 percent of full-time employment to participate in the Dependent Care FSA.  Participants using a Health FSA and/or Dependent Care FSA must complete an enrollment form to participate each plan year. Those employees that are new mid-year have 31 days from their date of hire to complete the form.

  • Flexible Benefits Enrollment Form 2018-2019 - Participants using a Health FSA or Dependent Care FSA are required to fill out a form every year. 

  • Employees using only the Pre-Tax Premium component are not required to fill out a Flex enrollment form.

Note:  Some web browsers may not be compatible with the format of this form.  If you have trouble with the form (fields not fillable or the Print/Save buttons not working), please download the form and save to your device, then reopen using Acrobat.  For most users, this will allow the form to be filled, saved, and printed.

For individual participant questions, please contact Laura Landstra at llandstra@csionline.org

For schools wanting more information about the Flexible Benefits Program, please contact Todd Schilthuis at tschilthuis@csionline.org.

 


 

Claims for Health Care and Dependent Care Expense Accounts

Option 1:  Submit claims online directly through Arcadia Benefits.  No claim forms are required.  Contact Arcadia or your HR Department for the Employer code if required. 


Option 2:  Complete forms and send via email or postal service.  Complete the claim form (see link below) and attach supporting documentation for reimbursement of health care and/or dependent care expenses.  This claim form can be submitted to Arcadia via email (info@arcadiabenefits.com) or via postal service to: Arcadia Benefits Group, 612 S Park St, Kalamazoo, MI  49007.


Note:  Participants who are enrolled in the Health Care FSA (General or Limited Purpose) will automatically receive a Benefits Debit Card.  There is no card issued for the Dependent Care FSA.  If a participant uses their card to pay for a qualified expense, they do not need to file a claim.  However, they may be required to submit back-up documentation of the expense. 

 


 

Change in Benefit Election Form

 


 

Direct Deposit Authorization Form

  • Direct Deposit Authorization Form - Complete this form to have your flexible spending account (FSA) reimbursements deposited directly into your checking or savings account or to change your checking or savings account numbers.

 


 

Dependent Care Certification Statement

 


 

Employee Status Change Form

  • Employee Status Change Form - The school must complete this form when an employee has a name change, address change, termination of employment, or leave of absence.

 


 

Cash Compensation in Lieu of Benefits Form

  • Cash in Lieu of Benefits Form - This form is used by schools that offer a cash incentive to employees eligible to opt out of the school's insurance plan.