Jem 125 cafeteria plan 2026

1. Click ‘Get Form’ to open the jem 125 cafeteria plan in the editor.
2. Begin by entering your Participant Name, Employer Name, Social Security Number, and contact information in the designated fields.
3. In the Out of Pocket Medical or Dental Expenses section, list any expenses not covered by a Group Medical or Dental Plan. Attach copies of paid receipts and EOBs as required.
4. For each expense, provide details such as Date of Birth, Relationship to Participant, Services Provided by, Date of Services, Total Expense, Payment by Insurance, and Out of Pocket Expense.
5. Indicate if any expenses are covered by Medicare or another Group Medical/Dental Plan and provide the necessary details.
6. Complete the Dependent Care Reimbursement section by listing dependent care expenses incurred. Attach relevant receipts from providers.
7. Finally, review all entries for accuracy before signing and dating the form at the bottom.

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