BASIC HRA Administrative Forms

BASIC HRA participant information change form
Use this form if an employee has a status change such as an increase in election, change in per pay, termination of coverage or address change. Type directly in the fillable PDF to ensure legibility.
Fillable PDF

BASIC HRA spreadsheet with MSP data collection – Over 20 Employees
Use this enrollment spreadsheet if you have more than 20 W-2 employees and their HRA benefit is $1,000 or more (not including rollover). Once completed please name the file your company name and upload to https://upload.basiconline.com/?los=hra.
Download excel spreadsheet

BASIC HRA spreadsheet – Groups under 20
Use this spreadsheet for initial group set up or for mid year enrollments. Once completed please name the file your company name and upload to https://upload.basiconline.com/?los=hra.
Download excel spreadsheet

BASIC HRA document change form
Use this form to make any changes to your plan including benefit coordinator change, plan year change or coverage change. Type directly in the fillable PDF to ensure legibility.
Fillable PDF

BASIC HRA new participant enrollment form
Use this form to add a new participant to your HRA plan. Type directly in the fillable PDF to ensure legibility. Don’t forget to have the employee sign the enrollment form before faxing.
Fillable PDF

BASIC HRA debit card refund form
Participants use this form when they need to refund their employer due to an ineligible debit card charge.
Fillable PDF

BASIC HRA claim forms
Claim forms