Flexible Spending Account (FSA) Claim Form
Last 4 SS#:
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Explanation of Benefits (EOB) must be provided as proof of expense. Detailed invoice/receipt may be accepted if no EOB is available.
EMPLOYEE'S CERTIFICATION FOR REIMBURSEMENT
I certify that the expenses for reimbursement indicated on this substantiation form were incurred by me (and/or my spouse and/or eligible
dependents), and were not reimbursed by any other plan nor will I seek reimbursement from any other source. To the best of my
knowledge and belief, the expenses are eligible for reimbursement under my Reimbursement Plan. 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: ________ /________ /________
FOR PROCESSING, SEND TO: Querbes & Nelson Benefits Department
MAIL: Querbes & Nelson
P.O. Box 1802
PHONE: (318) 429-0516
SHREVEPORT, LA 71162
MEDICAL FSA EXPENSE CLAIMS
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Name of Provider/
Centenary College of Louisiana
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