How to File a Claim

  1. Complete the claim form, listing all amounts claimed for reimbursement.
  2. Make sure claim does not include items for more than one Plan Year. Please use separate claim forms for items incurred in different Plan Years.
  3. Consult with your Plan Administrator for policies on handling bills, invoices, cancelled checks or other supporting documents.

IT IS YOUR RESPONSIBILITY TO PROVIDE SUPPORT FOR THIS CLAIM IN THE EVENT OF AN IRS AUDIT

Reimbursement Form

  • Date Expense Incurred Name of Provider Description of Services Provided Person for Whom Expense Incurred Amount Incurred  
             
    There are no Items.
  • Amount: $0.00
  • Drop files here or