FSA Forms - Alliance Insurance Group

Flexible Spending Accounts Brochure

Explains what Flexible Spending Accounts are, the benefits of participation, such as tax savings and provides a listing of qualified expenses.

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Online Access Instructions

Explains how to set up online access to verify balances, review transactions and follow up on reimbursements.

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Medical FSA Reimbursement Form

Use this form to submit reimbursements for qualified Healthcare expenses when you did not or could not use the Alliance Flex Card.

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Medical FSA Direct Deposit Form

Use this form to direct Alliance Insurance Group to direct deposit your reimbursements from manual (non-Flex Card) transactions directly with your bank. This form is typically used in conjunction with the Reimbursement Form.

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Dependent Care FSA Reimbursement Form

Use this form to submit reimbursements for qualified Dependent Care expenses when you did not or could not use your Alliance Flex Card.

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Dependent Care FSA Direct Deposit Form

Use this form to direct Alliance Insurance Group to direct deposit your reimbursements from manual (non-Flex Card) transactions directly with your bank. This form is typically used in conjunction with the Reimbursement Form.

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HSA Transfer of Assets

Use this form if if the assets will be transferred directly from your existing HSA, MSA, or IRA custodian.

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