Company Name: ____________________________________

Request for Reimbursement CLAIM FORM

 

NAME:	Last                                                                                                         First                                                      MI	SS#:
ADDRESS:	Street                                                                         City                                                             State               ZIP	PHONE :		(          )

Please check if this is a new address

Please read the Reimbursement Account Rules and Claim Filing Instructions before completing this claim.

Information below must be completed

 

FLEXIBLE SPENDING ACCOUNT ( FSA)  MEDICAL EXPENSE CLAIMS

Date of Service MM/DD/YY

Patient Name

Relationship

Description of Service

Claim Amount

$

$

$

$

$

$

$

$

$

DAY CARE CLAIMS

Date of Service From           To

Dependent Name

Age

Dependent Care Provider Name

Dependent Care Provider Address

Provider Tax Id#/SS#

Claim Amount

$

$

$

EMPLOYEE'S CERTIFICATION FOR REIMBURSEMENT

I certify that the expenses for reimbursement requested from my accounts were incurred by me (and/or my spouse and/or eligible dependents), were not reimbursed by any other plan, and, to the

best of my knowledge and belief, are eligible for reimbursement under my Reimbursement Plans. I (or we) will not use the expense reimbursed through this account as deductions or credits when

filing my (our) individual income tax return. Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider,

files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.

Employee Signature:___________________________________________       Date: ________ /________ /________

fax to (661) 280-2016

Or mail to: Shaffer Insurance Services, Inc.  Benefits Division 
902 East Avenue Q-9, Palmdale, CA 93550-4735