Get Wy Egi-105 2007-2026

The WY EGI-105 form is essential for users seeking reimbursement for medical expenses and dependent care costs under the Wyoming Flexible Spending Plan. This guide provides step-by-step instructions to ensure you complete the form accurately and efficiently, supporting you through the reimbursement process.

Follow the steps to complete the WY EGI-105 form successfully.

1. Click the ‘Get Form’ button to access the WY EGI-105 online and open it for editing.
2. Fill in your agency name and agency number in the specified fields.
3. Enter your social security number, last name, and first name in their respective sections.
4. Provide your home address, including city, state, and zip code. Check the box if you have a new address.
5. Input your daytime telephone number.
6. In the 'Request for reimbursement from the medical account' section, complete all fields including the service provider name, date of service, patient relationship, requested amount, and age.
7. Calculate the total medical reimbursement requested and fill it in the designated field.
8. Move to the 'Request for reimbursement from the dependent day care account' section and complete it in full, including name and ID number of the provider, date of care, dependent relationship, and requested amount.
9. Add up the total dependent care reimbursement requested and enter that amount.
10. Ensure that the dependent care provider signature section is completed, which may include attaching a receipt instead.
11. Sign the back page of the form as the employee, ensuring your signature is original.
12. Attach any necessary documentation, such as explanations of benefits (EOB) and itemized invoices.
13. Review the completed form for accuracy and clarity.
14. Save your changes, download the form, print it if necessary, and submit it as directed.

Complete your WY EGI-105 form online today to ensure timely processing of your claims!