Personal Information

• Company Name:
  
• Employee Name:
  
• SSN/Employee No:
• Daytime Phone:
• Email Address:
      Address on file is:
• 
  Plan Year:
• In-Office Check Pickup
  No Yes Select an option to indicate whether you will pick up your check at the offices of Southern Adminstrators & Benefit Consultants in Ridgeland, MS.
•  
• Dependent Day Care Expenses Total:
  $
• Unreimbursed Medical Expenses Total:
  $
  An Explanation of Benefits from your insurance carrier is always the preferred receipt, and may be required.
• HRA Expenses Total:
  $
  Employer Supplement Plan (EOB Required)
• If you are submitting receipts to Validate expenses that were paid using the SABCFlex (Wex) card, scan and submit the email sent to you along with your receipts.
• PLEASE NOTE! You are limited to 10 receipts per claim.
• And files are limited to 5 Megabytes in size per image. You may need to adjust your camera settings to obtain the correct size.
Receipt Images:
Click to Upload Receipts

To the best of my knowledge and belief, my statements in this Request for Reimbursement are complete and true. I am claiming reimbursement only for eligible expenses incurred after the effective date of my participation in the plan and only for eligible family members. I certify that these expense(s) have not been previously reimbursed or are not reimbursable under any other health plan coverage, and will not be claimed as an income tax deduction. I authorize my Flexible Spending Account be reduced by the amount of eligible expenses requested.