Claim one intranet 2026

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The document is a reimbursement claim form for Flexible Spending Accounts (FSA) related to dependent care expenses. It provides instructions for employees on how to submit claims, including required documentation and verification details. The form includes sections for employee information, service recipient details, and certification from the dependent care provider. It emphasizes the need for itemized receipts and outlines the reimbursement process.

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Click ‘Get Form’ to open the claim one intranet in the editor.
Begin by filling out the EMPLOYEE INFORMATION section. Enter your name, company name, last four digits of your Social Security Number, telephone number, and email address.
Complete the table for claim details. For each service, provide the name of the service recipient, their age (if under 13), start and end dates of service, service provider's name, and amount.
Ensure you attach copies of itemized bills or receipts that include necessary details such as service dates and provider’s name. Remember to use blue or black ink only.
If applicable, have your Dependent Care Provider sign the Certification From Provider section. Otherwise, ensure you have an itemized receipt.
Sign your claim form and submit it via fax or mail as instructed. Retain a copy for your records.

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