Get Employee Reimbursement Claim Form

Completing the Employee Reimbursement Claim Form online is a straightforward process that can help you efficiently request reimbursement for eligible expenses. This guide provides step-by-step instructions to ensure that you fill out the form correctly and provide all necessary information.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to acquire the form and open it for editing.
2. Fill in your employer's name and the date of submission at the top of the form.
3. Enter your Social Security number, last name, first name, and middle initial in the designated fields.
4. Provide your mailing address, including city, state, and zip code. This is where your reimbursement will be sent.
5. Input your personal contact numbers, including home and work phone numbers.
6. Select the type of expense you are claiming—medical, dental, vision, or hearing—and list the date incurred (date of service). Be sure to attach proper supporting documentation.
7. Provide the name of the claimant or patient, a description of the claim, and the total amount for each incurred expense in the relevant fields.
8. If claiming dependent care expenses, list the dependent care provider's name, their Social Security number or Federal ID number, the date incurred, and the claim amount.
9. Review your entries for accuracy and completeness to ensure you meet all requirements outlined in the Information Sheet.
10. After reviewing, you can save your changes, download a copy of the completed form, print it for your records, or share it as needed.

Start completing your Employee Reimbursement Claim Form online today to ensure you receive your reimbursements promptly.