Enrollee Information

Flexible Benefits - Claim Form

Expenses

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*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.
Agree with Authorization? *
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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
 
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FlexbeneTM
Your Flexible Benefits Administrator
Email: info@flexbene.com
Phone: 800-836-8100 & 585-385-6010
Fax: 585-248-2488