Forms

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Medical

Domestic Partner Affidavit

Health Savings Account

HSA Application

Submit all HSA applications directly to Heartland Bank via secure email – you will be asked to register before sending secure email.

Heartland Bank Secure Email

Email to: ftthomas@heartland.bank

Flexible Spending Account

Flexible Spending Account Claim Form

Provider website: WEX Health

Supplemental Life & AD&D

The Standard Evidence of Insurability Form*

The Standard Proof of Death Claim Form*

The Standard Accidental Dismemberment Employee’s Statement*

*Return to the Standard

401(k)

401k Rollover Form

401(k) Financial Hardship Form

401(k) In Service Distribution Form

Time Away From Work

Request for Leave Form

The Standard Long-Term Disability Form

Accident and Critical Illness

The Standard Accident Claim Form*

The Standard Critical Illness Claim Form*

The Standard Health Maintenance Claim Form*

The Standard Disability Insurance Form*

*Return to the Standard

Education Assistance

Fischer Homes Associate Education Reimbursement Form

Wellness Program

Wellness Affidavit Form

*Return to Wellness@Fischerhomes.com

Where to submit forms

Unless stated otherwise on the form, please return completed forms to payroll@fischerhomes.com
for timely processing.