HTML Preview Voucher Form (Blank) page number 1.
Flexible Spending Plan Reimbursement Voucher
*Please read the back of this form for instructions on how to complete this voucher *
Name of EMPLOYER
YOUR Name S.S. Number
YOUR Address (CHECKS WILL BE SENT TO THIS ADDRESS) City State Zip
PLEASE CHECK THIS BOX IF THERE IS A CHANGE OF ADDRESS.
Home Phone # Work Phone #
Unreimbursed Medical Expenses Dependent / Child Care Expenses
(Office Visits, Co-Pays, Vision, Dental, etc.) (Day Camps, Babysitters, Daycare Centers, etc.)
Receipt must include Nature of Service, Date of Service, and Amount Receipt must include Date of Service, Amount, and SS# or Tax ID#
?? Prescription for item # on file with PGP:
Nature of Service Date(s) Amount Name of Day Care Provider SS# or Tax ID #
1 $ 1
2 $ 2
3 $
4 $
5 $
Description of Service Date(s) Amount
6 $ 1 $
7 $ 2 $
8 $ 3 $
9 $ 4 $
10 $ 5 $
TOTAL $ TOTAL
$
Premium Expenses
(Privately held insurance policies)
Description of Service Dates of Service Amount
1 $
2 $
TOTAL $
This is to certify that I have incurred the expenses listed above for myself or qualifying dependents and that the expenses detailed above are eligible for reimbursement in accordance
with applicable governmental rules and regulations for cafeteria plans. I have enclosed copies of all bills for these expenses, including documentation of reimbursement to me,
if any, provided by other health coverage. I have retained originals or copies of all documents submitted. I understand and agree that since these expenses are to be reimbursed
they may not be claimed for my income tax. I also certify that none of these expenses have been previously submitted for reimbursement. I understand that should these expenses
be reimbursed to me by other health or benefit coverage ( i.e. duplicate payments), I shall return the monies paid to me by this plan, and the funds shall be re-credited to my account.
I hereby request that the plan reimburse me for expenses identified in this voucher and attachments.
X
SIGNATURE Date
Send completed vouchers to: Preferred Group Plans, Inc.
P.O. Box 15136
Albany, NY 12212-5136
(518) 641-0321 (800) 573-7474
Minimum Request:$25.00 Fax: (518) 641-0325 ?? SEE REVERSE FOR DETAILS