Online Claim Submission Form

Enter the Company Name of Employer

Claims under this plan are submitted by the plan participant.

No claim information submitted is ever shared with a 3rd party or transferred physically or electronically once received by assureflex.

Claims are subject to a $3.75 standard processing fee Claims under $100 are subject to an additional $5.00 processing fee

Confirmation, Authorization and Signature

I certify that the information provided on this form is correct to my knowledge and that all goods and services have been received and used by me, My spouse and/or dependents, and that the claims submitted here are for myself, my spouse or dependents; and that the claims submitted here are for myself, my spouse or dependents as defined as eligible under the terms of this plan, as outlined in your employee benefit booklet.

Signature of corporate signing officer

Enter Date of Signature

Online Claim Submission Form

Employee Reimbursement Section: Payment to Service Provider

Employee Reimbursement Section: Payment to Service Provider

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