Reimbursement Claim Form

When filing a claim please read the second page of the claim form for the directions and information needed to process the claim. We have also provided example claim for you to look at to have an idea of what is needed in order to process the claim. This can be located on the announcements page.

The deadline for submitting a claim for 2022 plan year is normally Tax day.

The deadline for 2023 will be April 30th 2023.

The deadline has past for filing a claim for any other previous plan years.

You can mail in the claim for to the address provided. If you would like to fax the claim in it must be legible and have a completed claim form with it. If you would like a digital link to upload to us you will need contact our office to request this service as it requires a couple of extra steps.