Below you will find a variety of claim forms due to the different plans we have available. Please read the description of each to find the appropriate claim form for your plan. If you have a question on which form you should use please call one of our customer service representatives at 888-472-0777.

BASIC HRA reimbursement form
Employees who do NOT have a BASIC HRA Debit Card use this form to request reimbursement from their BASIC Flex account.
Non Debit Card Users

BASIC HRA Debit Card reimbursement/verification form
Employees with a BASIC HRA Debit Card use this form to request reimbursement from their BASIC HRA account or to submit verification for card transactions. 
HRA Debit Card Users

BASIC Flex/BASIC HRA reimbursement form
Employees that have both a BASIC Flex and BASIC HRA plan use this form to request reimbursements.
Flex /HRA Users

BASIC Non Aggregate reimbursement form
Employees that have a non aggregate HRA plan use this form to request reimbursements.
Non Aggregate HRA Users