Please Check Plan You Are Submitting*
- Employee Only $3,500 In-Network Deductible - 1st $1,500 paid by Employee & 2nd $2,000 paid by Employer
- Family Coverage $7,400 In-Network - 1st $1,500 paid by Employee for each Family Member & 2nd $2,000 paid by Employer for each Family Member (Minimum of 2 family members required to meet dedectible)
Employee Name*
First Last
Employee Social Security#
Employee Phone*
Employee Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
New Address
- Check box if address is new
Spouse/Dependent Name*
First Last
Spouse/Dependent Social Security#*
Spouse/Dependent Date of Birth*
Month
Day
Year
Spouse/Dependent Gender*
- Male
- Female
Detail of Request*
Date of Service - Must be Itemized Name of Service Provider Expense Description Person for whom the expense was incurred* Enter the dollar amount
Total Amount Requested*
Attach Explanation of Benefits
Accepted file types: jpg, png, pdf, Max. file size: 64 MB.
CAPTCHA

Date of Service - Must be Itemized	Name of Service Provider	Expense Description	Person for whom the expense was incurred*	Enter the dollar amount