Employee/ Participant Name Employer/ Company Name Home Address Email Address
Employee Social Security #
City, State Zip Contact Phone
Date Incurred
Type of Expense*
Expense Incurred to Description of Expense
Name of Family Member
Relationship to Employee
Expense Amount
The undersigned participant in the Plan certifies that all expenses for which reimbursement or payment is claimed by submission of this form were incurred during a period while the undersigned was covered under the Company's cafeteria plan with respect to such expenses and that the medical expenses have not been reimbursed or are not reimbursable under any other health plan coverage. The undersigned fully understands that he or she alone is fully responsible for the sufficiency, accuracy, and veracity of all information relating to this claim which is provided by the undersigned, and that unless an expense for which payment or reimbursement is claimed is a proper expense under the Plan, the undersigned may be liable for payment of all related taxes including federal, state, or city income tax on amounts paid from the Plan which relate to such expense. If a fraudulent claim is filed, you will be responsible for paying back the fraudulent claim.
To submit: Scan and email this form and all receipts to flexpak@swerdlin.net Fax to (866)209-3517 Mail to FlexPak, c/o Swerdlin & Company, 5901 Peachtree Dunwoody Road, B-100, Atlanta, GA 30328 For questions, please email flexpak@swerdlin.net or call (866)353-9725. For balance inquiries, please visit www.flexpakcafe.net
Swerdlin & Company
Claim Form Instructions
To receive reimbursement for medical, dependent care and/or outside insurance expenses, you need to complete a Flexible Spending Account Claim Form. Instructions to complete this form are below along with an example of a completed form. You will need to attach receipts for all expenses on the claim form in order to receive reimbursement. Also, you will need a Dependent Care Vertification Form on file for dependent care expenses. The form is needed to verify the eligibility of your daycare provider. You only need to complete the form once for the current plan year, unless the information changes.
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Employee/Participant Information You will need to fully complete this section every time you submit a claim form. If you have a change of address, please check the change of address box. Expense Information Write down all eligible expenses* for reimbursement. You must include all details in this expense section: Date(s) Incurred: The date the expense was incurred. For example, if you paid a $20 co-pay for a doctor visit, use the date of the doctor visit. Type of Expense: Circle the type of expense. H = Healthcare expenses (dental, vision, doctor co-pays, prescriptions, etc.). D = Dependent care expenses (day care). Expense Incurred To/Description of Expense: On the top line, write down the place that the expense was incurred such as the name of the doctor. On the bottom line, write down what the expense was for, for example, "co-pay" if it was for a doctor visit. Name of Family Member: Write down the name of the family member that incurred the expense, not the person that paid the expense (unless it is the same person). Relationship to Employee: Write down the relationship to the employee of the family member named in the "Name of Family Member" column. Expense Amount: Write down the total amount of the expense (must match receipt). Total: Add all the amounts in the "Expense Amount" column and write it here. If you do not have the total amount in your account, you will be reimbursed for what is available. For dependent and outside insurance accounts, all receipts will roll forward until more funds are available. Authorization Sign and date form. Submission You can submit your claim form by faxing or mailing the form along with all receipts to: FAX: (866) 209-3517
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B
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B
C
D
E
F
G C
D
H
E
F
G
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H
Important Reminders Provide proper documentation/receipts for all expenses submitted. Sign and date the Claim Form. FlexPak cannot process the form without your signature. Multiple expenses may be included on one form. If more space is needed, attach additional forms (copy original form or download a blank form at www.flexpakcafe.net). Expenses for medical and daycare services must be incurred prior to reimbursement. Keep copies of everything submitted to FlexPak for your records. If you need copies, there will be a $25.00 fee. IRS guidelines require that FlexPak keeps records of all claims and correspondence for three years. For faster reimbursement, use direct deposit. Complete an Authorization for Direct Deposit form and submit to FlexPak. If you have any questions, contact a FlexPak representative at (866) 353-9725. For balance inquiries, visit www.flexpakcafe.net.
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MAIL: FlexPak c/o Swerdlin & Company 5901 Peachtree Dunwoody Road, B-100 Atlanta, GA 30328 * For a list of eligible expenses, see the Eligible Expenses for Medical and Dependent FSAs forms.
Instructions to Form EE-03