Online Claim Submission Form

Participant Identification

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 Eligible Employee

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Employee Reimbursement Section: Payment to Plan Participant

Reimbursement To Plan Participant

Provider Payment Section: Payment Assigned to Provider

Don't complete this section unless funds are to be paid to provider.

Reimbursements To Service Providers

Total Reimbursement This Claim

Upload Documents

Tap to Open Document Files on your Device, Select the Applicable Receipts and other supporting Documents.

Claim is subject to the Standard Processing Fee: $3.75