Claim Authorization - By submitting this form, I certify that the amounts listed are correct and are expenses that represent qualified reimbursable ex...
Flexible Spending Account (FSA) Questions and Answers 2016 FSAs How do I know if I have a balance remaining in my 2016 FSA ? You can view your account history in
MEDICAL EXPENSE REIMBURSEMENT ACCOUNT CLAIM ... If you are a member of a group plan that ... Complete and sign the Medical Expense Reimbursement Account Claim form
state of washington medical flexible spending arrangement (fsa) & dependent care assistance program (dcap) claim form. rev 6/16/2016 . for plan year january 1, 2017
T2491 v.03 11.06.2017. Page . 1. of . 8. 01-CA9674 H. SETTLEMENT REGISTRATION/CLAIM FORM. Auto Airbag Settlement for
Denplan Corporate claim form To help us settle your claim quickly please complete all sections as accurately as you can. ... Denplan Corporate, Denplan Ltd,
Account Transfer Form Instructions Important Instructions 1. Attach a complete copy of your most recent statement (within 90 days) for each account you are transferring
Operationai Instructicns. Account rryith Other Bank(s). Branch. Customer No. Account No. Dear Sir/Madam. I/we hereby request you to open an account in your bank on the name mentioned hereunder and agree to comply with and abide by the bank's rules in
SUBSCRIBER INFORMATION Primary Participant ID# (required) Company Employee Number (if appropriate) Plan Sponsor Last Name First Name Middle Initial
OTHER COVERAGE. Statement of Actual Services – OR –. Request for Predetermination / Preauthorization ... 40. Is Treatment for Orthodontics? Provider's Office. Hospital. ECF. Other. 45. Treatment Resulting from (Check applicable box). 47. Auto Acciden
Payee NRIC: Bank Account No:: Notification of payment will be sent to this email address. Important Notice: The Company shall (i) be discharged from all liability
Vanguard ETF through your Vanguard Brokerage Account for 60 days. 2 Vanguard Brokerage Services® charges a $20 annual account service fee. However, we don't charge the fee to: 1) Voyager, Voyager Select, Flagship, and Flagship Select clients; 2) clie
Denplan claim form To help us settle ... Denplan Corporate, Denplan Court, ... please make sure this is clearly stated on this claim form and your itemised receipt
Aetna International Claim Form . Please submit this completed claim form with itemized bills and receipts. A separate claim form is needed for each family
Completed Account Opening Application Form along with required documentation. 2. .... I/We declare that do not enjoy credit facilities with other bank(s)/any other branch of your bank and undertake to inform the bank in writing as soon as any credit
CITY OF PHILADELPHIA. RISK MANAGEMENT DIVISION - CLAIMS UNIT. 1515 ARCH STREET ... DATE OF BIRTH: SOCIAL SECURITY NUMBER: DATE AND TIME OF THE ACCIDENT/INCIDENT: ... THE CITY WILL PROVIDE AN AFFIDAVIT OF NO INSURANCE TO BE NOTARIZED. AFTER SUBMITTING
Zurich Australian Insurance Limited ABN 13 000 296 640, AFS Licence No. 232507. 5 Blue Street North Sydney NSW 2060. General Claim Form – Page 1 of 4. General. Claim form. ZU07392 - V3 03/14 - CW. AN-006478-2012. All relevant sections are to be answe
or your tenant, or related to you, give full details werknemer, ‘n huurder of ‘n familielied is, meld besonderhede Claim If a claim has been, or is being
CUSTOMER ACCOUNT TRANSFER FORM NOTE: You must attach your most recent statement for this transfer to be processed. Internal transfers do not require a statement
Download GLOBE GADGET CARE. CLAIM FORM. Important Information. 1. In order to submit your claim, please complete the relevant sections. This first page must be ...
Date of birth DDDDDDDD . Dental claim form . Bu Please ensure that you complete this form fully and return it to us with copies or uploads of your original receipts
National Health Insurance Company – Daman ... Reimbursement Claim Form ... healthcare services provided to me during the period of my insurance coverage with Daman
PLEASE READ BEFORE COMPLETING THE CLAIM FORM ‘ All claim forms should be submitted ... completed this form please post it to: Denplan Corporate Denplan Court
ACCOUNT TRANSFER FORM ClEARiNG NUMbER: 0015 (08/2013) PAGE 2 OF 3ATSATFF NY CS 7630717 08/13 NAO branch No. Account No. FA/PWA No. For Internal Use Only
ACCOUNT TRANSFER FORM PAGE OF 2 Medallion Signature Guarantee ACCOUNT TRANSFER FORM ClEARiNG NUMbER: 00 5 Please use a separate form for each account you are
Flexible Spending Account (FSA) Claim Form Claim Filing Options Online: File a claim online by logging into your account at www.dbsbenefits.com Fax/Mail: Complete form below and mail or fax to: Diversified Benefit Services, Inc. PO Box 260, Hartland, WI 53029 Fax (262)367-5938 For assistance please call (800) 234-1229. Participant Information Participant Name (please print): ________________________________________________ Email: _________________________________________________________ Last 4 Digits of SS#: Employer Name: ______________________________________________________________________ Address Change (if applicable): __________________________________________________________ Participant Signature: ____________________________________________ Date: ________________________ Health Care FSA (HCFSA) / Limited Purpose FSA (LPFSA) Claim Amount: _______________________ Date(s) of Service (list range if multiple dates): ________________ to ________________ Attach Documentation Showing: 1) Date of Service
2) Provider
3) Your Out-of-Pocket Expense
4) Type of Medical Expense (medical, dental, vision)
Dependent Care FSA (DCFSA) Claim Amount: _______________________ Name of Dependent Care Provider: _________________________________________ Service Start Date: ________________ Service End Date: ________________ Provider Federal Tax ID#: ______________________
or
Provider SS#: ________________________
Signature of Provider: _______________________________________________ (required if no receipt attached) Premium Reimbursement Account (PRA) Claim Amount: __________________ Premium Coverage Dates (within plan year): _____________ to ____________ Attach Documentation Showing: Independent insurance premium billing. Claim Authorization - By submitting this form, I certify that the amounts listed are correct and are expenses that represent qualified reimbursable expenses. I will not claim these items on my personal income tax return for medical itemization nor claim any dependent care reimbursement expenses as a tax credit. I certify that I will not be reimbursed for the expenses listed above from any insurance company or insurance plan or the following: any other Flexible Benefit Plan, Medical Savings Account (MSA), Health Reimbursement Arrangement (HRA), Health Savings Account (HSA), another reimbursement plan or any other source. I also certify that the expenses have been incurred (having dates of service) during the timeframe required by the benefit plan and are for my own expenses, expenses of my spouse and expenses of my dependent children as defined by my employer’s Plan. I will provide documentation necessary to support the amounts being requested for reimbursement. In addition, by submitting this document I acknowledge and agree DBS may, in the case of an overpayment (fraudulent, inadvertent or otherwise), offset future expense reimbursements to me to account for such an overpayment. I also agree to immediately inform DBS if I become aware of an overpayment and agree to reimburse the Plan Sponsor to the extent that an offset of future reimbursements is either impossible or inconvenient.
