Forms

Select one of the Forms by clicking on the corresponding link below. Each form is editable and can be filled out when it is opened. Once you have finished filling in the necessary information on the form, print the PDF file, sign and mail or fax toll free to (888) 211-1392.

Authorization Agreement for Direct Deposit Form
Cafeteria Plan Medical
Cafeteria Plan - Dependent Care Claim
Change of Benefit Election or Drop Form
Debit Card Enrollment Form
Debit Card Substantiation Form
HSA Enrollment Form
Recurring Dependent Care Claim Form


Note: In order to view, fill out and print the above forms, you will need to have Adobe Reader®, which is available FREE from Adobe®. Click on the icon below to download.



NTALife Business Services Group, Inc.®

Mailing Address
CLAIM REIMBURSEMENT DEPT.
P.O. BOX 1392
ADDISON, TEXAS 75001-1392

Fax Toll-free
(888) 211-1392