Documents and Forms

Need to download or review an information document for your plans? Select the benefit below to see a listing of available forms, click the link to view or download the PDF of the form/document.

General

Application for ASi Services
Apply Online for services or download the form to fill out if you’re interested in applying for services with ASi. (link to separate landing page for Employer Application)

Employee Enrollment/Change of Status Form
This document is for your employees to fill out when electing coverage or if they are adding a dependent.

Employee Enrollment Template (Excel)
You can use this template to send ASi your employee enrollment status.

Authorization for Electronic Funds Transfer
An authorization form for setting up Automatic Clearing House transfers. Use for HRA, FSA, HSA, and/or MEC plans.

ASi Visa® Card Employer Setup Guide
Download this guide to walk you through how to set up the ASi Visa® Card account. Use for HRAs, FSAs, and/or HSAs plans.

Bancorp ACH Form
Use this form to set up the Automatic Clearing House for Bancorp (ASi Visa® Card) account. Use for HRAs, FSAs, and/or HSAs plans.

WEX Cloud Health Employer Login Request
A form to authorize you and certain employees access to the Employer Online Portal.

WEX Cloud Health Employer Quickstart Guide
Download this guide to help you with how to use your online portal.

Health Reimbursement Arrangements

EOB Retrieve Form
Your employees will need to fill out the Voluntary Authorization form on the second page of this document to enroll in EOB Retrieve.

Flexible Spending Accounts

FSA Employee Enrollment Authorization Form
This form is used to inform ASi of enrollment authorization.

Commuter Benefit Accounts

Commuter Benefit Accounts Employee Enrollment Authorization Form
This form is used to inform ASi of enrollment authorization.

Healthcare Benefit Compliance

ERISA Compliance Checklist
Use this checklist to see if you are in violation of ERISA regulations.

Mandatory Requirements for Health Benefit Compliance
Use this checklist to see if you are following all the Health Benefit Compliance mandatory requirements for your business(s).

Understanding Your Fiduciary Responsibilities Guide
This guide gives a simplified explanation of the laws and requirements if you offer a group health plan.

Health Savings Accounts

HSA Employee Enrollment Authorization Form
Use this form to notify ASi of employee enrollment in plan.

San Francisco Healthcare Security Ordinance

HCSO Workplace Poster – Required to Post
This poster must be printed and posted in your employee break room.

Employee SF HCSO Voluntary Waiver Form
This form should be signed by your employees if they are voluntarily waiving their right to receive healthcare from your company.

Quarterly Reporting Template (Excel)
Use this excel spreadsheet to inform ASi of your eligible employee’s hours and status.