Health Reimbursement Arrangement (Hra) Claim Form
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1HEALTH REIMBURSEMENT ARRANGEMENT PLAN (HRA)
Claim Form
Company: ___________________________ Employee Name: _______________________
This claim form is to be used only to request reimbursement from your Health Reimbursement
Arrangement (HRA) for health care expenses. When requesting reimbursement, your explanation of
benefits or other receipts allowed by your specific Plan showing that you incurred this expense, must be
submitted with this claim form.
IN ALL CASES, YOU MUST SIGN THE BOTTOM OF THIS FORM
Date Expense
Name of Service Provider
Expense Description
Relation to Person for
Amount
Incurred
Whom Expense Incurred
(i.e. self, child, spouse,
legal same-sex spouse)
Total
The undersigned participant in the Plan certifies that all expenses for which reimbursement or payment is claimed by submission
of this form were incurred during a period while the undersigned was covered under the HRA Plan. The undersigned fully
understands that he or she alone is fully responsible for the sufficiency, accuracy and veracity of all information relating to this
claim which is provided by the undersigned and that unless an expense for which payment or reimbursement is claimed as a
proper expense under the Plan, the undersigned may be liable for the payment of all related taxes including federal, state or city
income tax on amounts paid from the Plan which relate to such expense. The undersigned fully understands that no medical
expense tax deduction or credit is permitted for which reimbursement is made.
_________________________________________
_________________________
Employee Signature
Date
When done, attach all necessary receipts and mail, e-mail or efax to:
Northeast Benefits Management, LLC
P.O. Box 2363, South Burlington, VT 05407-2363
Scan and email:
eFax: (802) 304-1009 (Burlington exchange)
eFax: (802) 304-1067 (Burlington exchange)
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