Fsa Reimbursement Claim Form Page 2
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2Flexible Spending Account Benefit Plan
Claim Form & Filing Instructions:
1. On the reverse side of this page is a claim form. Please feel free to copy this form.
2. When filing your claim, you must attach copies of the receipts.
3. The receipt must show the date and type of service for the expense.
4. Canceled checks, credit card slips, or statements showing only a balance due on your account
are not allowable.
5. Please be sure to number each attachment page (i.e., Page 2 of 3, Page 3 of 3, etc.)
6. Please fax your claim with receipts to 301-977-5660. After you fax a claim and receipts, please do not
follow-up with a hard copy in the mail.
7. Please remember to keep a copy of the claim form and supporting documents for your records.) If you
choose to mail your claim with receipts, the address is:
The 125Company, Inc. PO Box 2401 Germantown, MD 20875-2401.
8. To verify that your claim has been received, please go to the Web site described below. When your
claim is approved, it will appear within two business days on the Web site under "view account."
(Remember to keep the original claim form and supporting documents for your records.)
9. You may check your account balance status any time, day or night at the Web site.
10. In addition, the Web site has a claim form, a list of qualifying expenses, and other administrative
tools that will help you conveniently manage your account.
11. The site also has frequently asked questions and instructions on how to contact us.
12. The Web site address is
has everything you need to manage your Flexible Benefit Account!
Change in status rules
Verify your election
Eligibility requirements
View your account balance
Calculate your tax savings
Print claim forms
Learn about the plan
How and where to file claims
How to contact us
Look up qualified expenses
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