Employers

Welcome and thank you for allowing us to service your Section 125 Cafeteria Plan. Download the entire Employer Welcome Packet (non-debit card or debit card) or individual documents below:

• Change in Status
• COBRA form
• COBRA form- sample
• Direct Deposit Agreement
• Direct Deposit Notice
• MyFlexOnline Website instructions – non-debit card
• MyFlexOnline Website instructions – debit card
• NOTICE OF PRIVACY PRACTICE - Protected Health Information
• Notice of Termination
• Participant Guide to Flexible Spending Accounts
• PIOPAC FIDELITY HIPAA PRIVACY COMPLIANCE STATEMENT
• PIOPAC FIDELITY PRIVACY POLICY AND PROCEDURES
• FSA/HRA Reimbursement Request form
• Trans/Park Reimbursement Request Form
• Reimbursement Request - addendum
• Salary Redirection Agreement (SRA)
• Employee Enrollment – Change Form
• Insurance Claim Form
• No Receipt Retailers for your take care® Debit Card
• Current PIOPAC W-9 Form
• Current IRS Indexed Figures

• ACH Debit Agreement

• Salary Redirection Agreement (SRA) - Trans/Parking

If you participate in the Debit Card program, refer to the frequently asked questions.

Participants can submit requests for reimbursement by scanning and emailing to FSAclaims@piopac.com, or faxing to (808) 536-0430, or by mail to 1132 Bishop Street, #2101, Hon., HI 96813.  Claims received via the U.S. Postal Service should have all receipts itemized and taped to a full letter size sheet of paper in order to avoid claim denial and to speed up reimbursement.

We highly encourage Direct Deposit as the most efficient method for participants to receive reimbursement. If a participant elects to receive a check and it is lost or not cashed within 60 days, there will be a $28.00 service fee to replace it.