Enrollee Information

Flexible Benefits - Claim Form

Expenses

calendar

calendar

calendar

calendar

*AUTHORIZATION: To the best of my knowledge and belief, my statements in this Reimbursement Voucher are complete and true. I am claiming reimbursement only for eligible expenses incurred during the applicable plan year and for the eligible plan participants. I certify that these expenses have not been previously reimbursed by this or any other benefit plan and WILL NOT BE CLAIMED AS AN INCOME TAX DEDUCTION.*
Actual receipts must be submitted. If receipts are not attached to this online claim form, copies of receipts must be submitted by mail, fax, or email within 30 days of reimbursement or your account will be debited.
Agree with Authorization? *
0/255 characters
Questions?? > > Don't hesitate to call us at
(585) 385-6010 or (800) 836-8100
 
 
Flexbene
PO Box 587
Pittsford, NY 14534
Fax: (585) 248-2488
info@flexbene.com
 
Home
Secured by Formsite