Riata Financial Group offers downloadable Acrobat forms for various insurance needs. If you have any questions about how to fill these forms out for your particular needs, just give us a call at (830) 606-5100. You will need Adobe Acrobat software to read and print these files. If you need to download the free Acrobat software, you can get a copy here. Just choose the form(s) you need from the links below, print and fill out the form and FAX it to us at:

(830) 606-2558

Click on the form title to read more about each before downloading. Section 125 Benefit Election Plan Form  Medical Expense Enrollment Form  Reimbursement  Change of Status Form 

Section 125 Benefit Election Plan Form
    Section 125 plans allow businesses to save Social Security (FICA), as well as federal unemployment taxes (FUTA) and generally, state unemployment taxes, on the money employees contribute to their premiums. Employer tax savings can average 7 to 10 percent of employees' contributions.

Premium contributions are automatically deducted from employee salaries before taxes are taken out. Because their taxable income is reduced by the amount they contribute, employees pay less taxes on the money they earn. Employees see a savings in their FICA, federal, and, in most cases state, income taxes. When employees become more aware of how they spend money on benefit items, they also tend to practice more cost-containment, resulting in savings for everyone. 

Section 125 Benefit Election Plan Form
Medical Expense Enrollment Form
    Medical/Dental Reimbursement Account worksheet for a IRS Code Section 105 Account.
Expenses not covered by the employer plan may qualify as eligible expenses reimbursable under Accident and Health coverage. If the plan is not totally funded or paid by the employer's medical plan, employees may make annual elections and have these deductions placed in his/her Medical/Dental Reimbursement Account.
Annual elections are most generally payroll deducted from the employee's paycheck on a per pay period basis, and deposited in the employee's Reimbursement Account. These payroll deduction amounts are made on a Pre-Tax basis.
When an eligible expense is incurred, the employee submits these expenses (much like filing an insurance claim form) and completes an expense voucher from which they are reimbursed on a Pre-Tax basis.

Medical Expense Enrollment Form 
Dependent Care Reimbursement
    Dependent Care Assistance for employees is covered under Code Section 129, and may be provided through use of reimbursement accounts, flexible spending accounts or actual on site facilities.
Elections and benefits are limited to $2,500 or $5,000 annually depending on whether the employee's tax filing status is joint or separate.
Elections are payroll deducted on a Pre-Tax basis and placed in the employee's Dependent Care Assistance Account. IRS requires receipts to be submitted monthly.
It is important to note that Dependent Care Reimbursement expenses do not have to be just for child(ren). These expenses may also cover expenses for elder care.

Reimbursement Voucher
    Flexible Spending Accounts allow employees to pay for health care expenses for themselves and their families which are not covered by health insurance including dental, vision, orthodontia, etc. (and even those deductibles or "co-pays" which are the patient's responsibility) with TAX-FREE dollars. 


Change of Status Form
    You can cancel or change your participation in the Plan only if you have a change in family status. The allowable changes in family status include: Marriage or Divorce  Death of spouse or dependent child  Birth or adoption of child  Change from part-time to full-time employment or from full-time to part-time employment by you or your spouse  Commencement or termination of your spouse’s employment  Taking an unpaid leave of absence by you or your spouse Significant change in your or your spouse’s health coverage, attributable to your spouse’s employment.

Change of Status Form