Fillable Claim Form Navia printable pdf download

Claim Form

(Instructions on next page)

Employee Information

Last Name, First Name

SSN / Employee ID #

Home Address

Phone Number

(Street, City, State, Zip Code)

Please update my address on file



Employer Name

Email Address

Did you know you can submit paperless claims online or via the MyNavia mobile app?

Just take a picture and submit!

Day Care FSA Expenses

Provider’s Name, Tax ID and/or

Service Date(s)

Type of Service

Services For Whom

Age

Net Cost

SSN

Total Reimbursement Request $ ____________________

Day Care Provider Certification: I certify that dependent care services were provided as indicated above.

Provider’s Signature X____________________________________________________________

Provider/Facility Name: ___________________________________________

Signer’s Name (Printed): __________________________________________

Date: ________________________________________________________________________

Healthcare/Limited FSA/HRA Expenses

Service Date(s)

Type of Service

Provider’s Name

Services For Whom

Net Cost

Total Reimbursement Request $ ____________________

Signature

To the best of my knowledge my statements on this claim form are complete and true. I understand that I am solely responsible for the sufficiency,

accuracy, and veracity of claims and all information related to these claims submitted to my HRA, Health Care (“HCFSA”) or Day Care Flexible Spending

Arrangement (“DCFSA”), and that unless an expense for which payment or reimbursement is claimed is a proper expense under the HRA, HCFSA or DCFSA,

I may be liable for the payment of all related taxes including federal, state or city income tax on amounts paid from the HRA, HCFSA or DCFSA which relate

to such expense. I further understand that no day care tax credit is permitted for amounts for which reimbursement is made. I am claiming health care

reimbursement for eligible medical care expenses incurred by myself, spouse and/or dependents. Note: The IRS does not recognize Domestic Partners for

purposes of receiving tax-favored health benefits. For further information please contact your employer. I certify that these expenses have not been

reimbursed under this plan or by any other source and that they will not be reimbursed by any other source or insurance. By providing an email

address, I consent to receive all possible communications from Navia Benefit Solutions, agents, and subcontractors regarding the Plan via email. I may

withdraw consent at any time without charge by contacting Navia by phone, email, or mail. To update your email address contact Navia Benefit Solutions

by phone, email, or mail. You have the right to receive paper version of an electronic document free of charge. Software requirements will be provided

with each electronic document. I hereby authorize my HRA, HCFSA and/or DCFSA to be reduced by the amount(s) shown above.

Participant’s Signature X_______________________________________________________________________________

Date_______________________________________________

REV 9/18/2015