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BASIC Flex Claim Forms

BASIC is pleased to announce a new process for the submission of claims and verifications.

We have created a secure claim upload portal for claim/verification submission. This new process allows you to complete a reimbursement request or verification form, attach documentation and receive confirmation that your submission was successfully uploaded. Please  submit your reimbursement/verification request here.

BASIC Flex 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 (pdf)

BASIC Flex Benefits Card Reimbursement/Verification Form

Employees with a BASIC Flex Debit Card use this form to request reimbursement from their BASIC Flex account or to submit verification for card transactions.
Flex Debit Card Users (pdf)

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 (pdf)