Get New Reimbursement Form - Allied Benefit Systems

This guide provides a comprehensive overview of how to complete the New Reimbursement Form for Allied Benefit Systems online. Users can follow these clear steps to ensure accurate and timely submissions of their reimbursement requests.

Follow the steps to complete your reimbursement form easily.

1. Press the ‘Get Form’ button to obtain the New Reimbursement Form - Allied Benefit Systems and open it in an editable format.
2. Begin by filling in Section I, which includes providing your group number, employer name, and employer location, if applicable. Ensure the employee's name, social security number, flex plan year, address, city, state, employee email address, and daytime phone number are accurately entered.
3. Move to Section II to detail your reimbursement request. Under the Health Flexible Spending Account (FSA) Expense(s), list the type of expenses such as medical, dental/vision, RX, and OTC/other. Enter the date of service and the amount for each expense.
4. For dependent care assistance (DCA) expenses, specify the name of the dependent for whom expenses were incurred, alongside their age. Again, fill in the date of service and the amount of expenses.
5. Ensure to attach all relevant receipts for the requested reimbursements. For dependent care, include receipts or the Tax ID and signature of the dependent care provider.
6. Review the total reimbursement requested at the bottom of Section II and verify that the amount is accurate.
7. Proceed to Section III, the participant certification. Here, confirm that all stated expenses meet the conditions outlined and sign and date the document to certify the accuracy of your provided information.
8. Once all sections are completed, save your changes. You can choose to download, print, or share the document as needed.

Complete your reimbursement forms online to ensure your expenses are processed smoothly.