Employee Benefits Claims

FSA Claim Form

Please use this form for your Section 125 Cafeteria Plan Flexible Spending Account. This form is for any unreimbursed qualified medical and dependent care expenses. If you do not have an FSA and you use this form, there is a possibility your claim will be denied.

HRA Claim Form

Please use this form for your Health Reimbursement Account. This form is used only for HRA participants. If you do not have an HRA and you use this form, there is a possibility your claim will be denied.