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- Click ‘Get Form’ to open the FLEX CLAIM FORM in the editor.
- Begin by entering your EMPLOYEE NAME and SOCIAL SECURITY NUMBER in the designated fields. If you have changed your name or address, please provide that information as well.
- In the FLEXIBLE BENEFIT PLAN section, fill in your new address details including Street, City, State, and Zip code.
- Attach necessary substantiation documents for your claims. For medical expenses, include an Insurance Explanation of Benefits (EOB) or a medical provider invoice. For dependent day care claims, ensure invoices are itemized with required details.
- Specify the amounts you wish to be reimbursed for Medical Expenses and Dependent Day Care Expenses (DCAP).
- Answer the two questions regarding DCAP claims accurately to ensure processing. Provide details about payment frequency and any days not worked during the claim period.
- Itemize and total your expenses in the provided table, ensuring all necessary information is included.
- Finally, review your entries for accuracy, sign and date the form before submitting it through our platform.
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