Shaffer Insurance Services, Inc.

  • 902 E Avenue, Q-9
  • Palmdale, CA 93550
  • Phone: 661-410-7048
  • Fax: 661-274-4272

Office Hours:

Mon: 9:00 AM – 5:00 PM
Tues: 9:00 AM – 5:00 PM
Wed: 9:00 AM – 5:00 PM
Thurs: 9:00 AM – 5:00 PM
Fri: 9:00 AM – 4:00 PM
Sat: Closed
Sun: Closed

Select Page
661-410-7048

Reimbursement Claim Form

Request for Reimbursement – Claim Form


After filling out form, please scroll to the bottom and hit Submit.

Scan and email any receipt(s) to darlene@shafferins.com.

First Name
M.I.
Last Name
Address
City
State
Zip
Employer Name
Work Phone Number

(FSA) Medical Expense(s) to be reimbursed

Date of Service (MM/DD/YYYY)
Patient Name
Relationship
Name of Provider
Description of Service
Claim Amount
Date of Service (MM/DD/YYYY)
Patient Name
Relationship
Name of Provider
Description of Service
Claim Amount
Date of Service (MM/DD/YYYY)
Patient Name
Relationship
Name of Provider
Description of Service
Claim Amount
Date of Service (MM/DD/YYYY)
Patient Name
Relationship
Name of Provider
Description of Service
Claim Amount
Date of Service (MM/DD/YYYY)
Patient Name
Relationship
Name of Provider
Description of Service
Claim Amount
Total Claim

Dependent Day Care Claims (Only)

Service Start (MM/DD/YYYY)
Service End (MM/DD/YYYY)
Dependent Name
Age
Dependent Care Provider Name
Dependent Care Provider Address
Provider Tax ID
Claim Amount
Service Start (MM/DD/YYYY)
Service End (MM/DD/YYYY)
Dependent Name
Age
Dependent Care Provider Name
Dependent Care Provider Address
Provider Tax ID
Claim Amount
Service Start (MM/DD/YYYY)
Service End (MM/DD/YYYY)
Dependent Name
Age
Dependent Care Provider Name
Dependent Care Provider Address
Provider Tax ID
Claim Amount
Service Start (MM/DD/YYYY)
Service End (MM/DD/YYYY)
Dependent Name
Age
Dependent Care Provider Name
Dependent Care Provider Address
Provider Tax ID
Claim Amount
Service Start (MM/DD/YYYY)
Service End (MM/DD/YYYY)
Dependent Name
Age
Dependent Care Provider Name
Dependent Care Provider Address
Provider Tax ID
Claim Amount
Total Claim
EMPLOYEE'S CERTIFICATION FOR EMPLOYMENT
I certify that the expenses for reimbursemet 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 decieve 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.