Allied Benefit Systems, Inc. P 800.288.2078
200 West Adams, Suite 500 F
Chicago, IL 60606 E flexclaims@alliedbenefit.com
Group Number Employer Location
(if applicable)
Employee UID or SSN
Flex Plan Year
Address Cit
State Zip
Dental/Vision
Provider's Signature (or attach receipt)
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- I have not and will not itemize and deduct nor claim credit for these expenses on my income tax returns.
- I understand that reimbursement will be made in accordance with the provisions of the Plan.
Employee Signature Date
312-416-2870
$
$
Date of Service
SECTION A - EMPLOYER/EMPLOYEE INFORMATION
SECTION B - REIMBURSEMENT REQUEST
Please attach all receipts that apply to required reimbursements. For dependent care, please attach receipts and signature of the
Dependent Care Provider.
HEALTH FSA EXPENSES
Employer Name
Daytime Phone
Employee Name
Employee Email Address
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$
Date of Service
DEPENDENT CARE ASSISTANCE EXPENSES
$
$
Amount of ExpensesOtherRxMedical
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$
$
Total Reimbursement Requested:
$
Name of Dependent Expenses Were
Incurred For Dependent(s) Age Amount of Expenses
$
Total Reimbursement Requested:
$
Provider's Tax ID Number or SSN
The above expenses were incurred for services or supplies for me and/or my eligible dependents listed above who reside with
me in a parent/child relationship or are legally dependent on me for their support.
The above services and supplies were furnished to me or my dependents on or after my effective date with the Plan.
I have not been reimbursed for the above expenses, nor have any of my dependents been reimbursed for these expenses.
I understand that any amounts not used for qualified expenses by the end of the Plan Year or Grace Period will be forfeited to my
Employer.
SECTION C - EMPLOYEE CERTIFICATION
I certify that the expenses for which I am requesting reimbursement meet the following conditions:
click to sign
signature
click to edit
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