IRS SECTION 125 FLEXIBLE SPENDING ACCOUNT
MEDICAL REIMBURSEMENT AND DEPENDENT CARE
CLAIM FORM
THIRD PARTY CLAIMS ADMINISTRATOR
COMBINED INSURANCE SERVICE (CIS),
814 East Silver Springs Blvd, Suite E, Ocala, FL 34470, (800) 473-
2181.
MEDICAL REIMBURSEMENT
Attach a copy of the invoice/bill/receipt, etc., for reimbursement of your expenses. If the expense is covered under
your insurance plan it should be submitted to your insurance carrier first. Once you receive your insurance statement,
attach the statement to this form for reimbursement of your portion of the expenses.
DEPENDENT CARE REIMBURSEMENT
Attach a copy of your receipt for dependent care expenses showing who was paid, for what dependent, and for what
dates. Qualifying dependents are children under the age of 13, a disabled spouse or other dependents who are
physically or mentally incapable of self-care. Both you and your spouse must work or one must be a full-time
student in order to file for dependent care expenses.
DEADLINE FOR SUBMISSION OF CLAIMS
th
All claims must be submitted for reimbursement by the 90
day following the Plan Year. Claims submitted after
this date will not be processed.
CLAIM INFORMATION
Claims may be mailed to: Combined Insurance Services, Inc.
PO Box 2438
Ocala, Fl 34478
Claims may be faxed to: Claims Adjuster
(352) 237-2040
EMPLOYER:_____________________________________________________________________
DAYTIME
EMPLOYEE:________________________ SOC. SEC. #:______________ PHONE___________
TYPE OF CLAIM
DESCRIPTION
AMOUNT
Name of Dependent:_________________
DEPENDENT CARE:
Period Covered:
From___________________
To_____________________
$____________
Service Provider:____________________
MEDICAL:
Date of Service:
__________________________________
$____________
I certify that the above information is correct. I further certify that these expenses have not been previously
reimbursed on this or any other benefit plan and will not be claimed as an income tax deduction. I am
claiming reimbursement only for eligible plan participants and understand that the Flexible Spending Accounts
are a provision of the IRS Section 125.
EMPLOYEE'S SIGNATURE:
DATE: