Employee Reimbursement Account (ERA)
Forms and Brochures

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2012 ERA Benefits Booklet

Automatic Premium Conversion Waiver/Revocation of Waiver (ET-2340)

Capital Expenditure Worksheet

Change in Status Form

FBMC Authorization for Release of Information

Letter of Medical Need

Medical Expense Account Continuation Election Form (ET-1518)

Personal Use Statement

Rapid Refund Authorization Form

Reimbursement Request Form (Before submitting this form, make a copy for yourself)