Understand the contents of an employee benefits corporation claim form plus a sample of it.

Employee benefits corporation claim form

One way organizations use to retain their best employees is by providing them with employee benefits. These can range from medication covers to retirement plans. There are those benefits that are arranged internally and those, which are required by the labor unions and the government as a right for every employee. In order to ensure that employees only claim for the benefits they are entitled to, it is important to design employee benefits corporation claim form. What should constitute the form?

Usually, the claim form has three important sections including:

Account holder information

In this section, one is required to fill in their two names, the first and the last. In addition, they need to fill in their social security number or an identification number.

Benefit codes

Next, the person filling the employee benefits corporation claim form should align the right codes with the benefits. For instance, retirement benefits have a different code than the one for medical insurance. You should make no mistakes since errors can delay the process. If you have Health Care FSA, the code is (F) whereas the code for DependentCare FSA is (D).

Claim section

In this section ensure to include information such as date of service (start and end date), the amount in dollars for each claim, description of service, the name of the provider and the total of the amount to be reimbursed in dollars for the whole page.

Prior to submission, it is important to acquaint yourself with the following information:

  1. It will take about three days upon the submission of your claim form before you can check the status of the account.
  2. Any claim documentation should contain the date of service, provider name, description of the costs incurred and the total costs.
  3. Non-itemized credit card receipts or canceled checks are not considered as credible claim form documentation.
  4. Maintain copies of the documentation you send to the claim corporation.
  5. When claiming for FSA expenses, similar services can be put in one line.

Employee benefits corporation claim form sample

Account holder information

First Name: […] Last Name: […]

Email Address:[…] Employer:[…]


Benefit Codes: H HRA L Limited Health Care FSA F Health Care FSA D Dependent Care FSA I Indv Billed Ins Premiums

Daycare Provider Signature (Dependent Care FSA Only)

Benefit code (D)          

Service Start Date (mm-dd-yyyy)    Description of Service

Provider: […]

End Dates

Person Receiving Service (HRA Only)

Claim Amount $

This certifies that my claims in this form are true and complete. I am claiming reimbursement only for covered expenses incurred by eligible dependents. It is in my understanding that my responsibility is to claim only eligible costs according to my company’s standards. The employee benefits corporation may need my health information, which might be disclosed to my employer. By putting my signature on this form, I agree that the employee benefits corporation should use the information in the processing of this plan. My failure to sign this claim form may deny me the opportunity to get a reimbursement.


These articles may interest you