LOGINS: Management Employee Login and Registration

SABC FlexCard Company Application

for 2020

* Company Name:

* Your Name:
Previous Address

Address Line 1:

Address Line 2:

City State: Zip:

Card Options Program Type
Open Card HRA

Grace Period Standard
2 1/2 Month Extension

Card Embossing Plan Year Begin Date Plan Year End Date

Card embossing limited to 20 characters.

Group Health Plan Name Group Health Plan Number


Office Visit Specialists Emergency Room Other

Prescription Co-Pays

Generic Preferred Non-Preferred Specialty Other

Vision Co-Pays (if applicable)

Materials Exams Other

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