Raytheon fsa claim form: Fill out & sign online

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Click ‘Get Form’ to open the Raytheon FSA Claim Form in our editor.
Begin by filling out the Retiree Information section. Enter your name, Social Security number, address, city, state, zip code, and daytime telephone number accurately.
In the List of Expenses section, ensure you attach copies of bills or other proof of expenses. Remember that cancelled checks are not sufficient evidence. Include 'Explanation of Benefits' (EOBs) from your medical plan as required.
For each expense, provide details such as the name of the retiree or dependent receiving service, their relationship to you, types of service rendered, dates of service (from and to), and the amount to be reimbursed.
Complete the Authorization section by signing and dating the form to certify that all information is accurate and that expenses have not been reimbursed elsewhere.
Finally, submit your completed form by returning it to the Raytheon Benefit Center at the provided address.

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