Get Fsa Reimbursement Claim Form. Section 125 Cafeteria Plan

Filling out the FSA Reimbursement Claim Form is a crucial step in managing your flexible benefits effectively. This guide will provide you with comprehensive, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to efficiently complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in your personal information including your name, social security number, address, date of birth, hire date, and email address in the appropriate fields.
3. Indicate your cost per pay by selecting one of the options provided. This may involve choosing between the healthcare reimbursement account and dependent care reimbursement account. Specify the amount you wish to set aside per pay period, ensuring it adheres to the maximum limits listed.
4. If applicable, indicate your interest in the premium savings account for YMCA-sponsored plans by marking ‘Yes’ or ‘No’ for medical, dental, and Aflac insurance.
5. Complete the section for the health savings account by entering the amount you wish to set aside each pay period.
6. Calculate and enter the total per pay deduction in the designated field to reflect all selections made.
7. Review the authorization of participation statement carefully. By signing, you acknowledge your understanding of the tax implications and conditions of the plan.
8. If you choose not to participate, complete the waiver of participation section by signing and dating it appropriately.
9. Finally, return your completed form to your human resources department for processing.

Complete your FSA Reimbursement Claim Form online today for efficient processing of your benefits.