Southern Administrators & Benefit Consultants, Inc.
Request for Reimbursement
(Submit separate request forms for each plan year.)
SSN (or 9-digit Employee No.):
numbers only, no hyphens
Employee Name will automatically populate.
Company Name will automatically populate.
In-Office Check Pickup:
Check here to indicate that you will pick up your reimbursement check at the
offices of Southern Administrators & 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 (Benny) card,
check this box
scan and submit the email
sent to you along with your receipts.
Please upload only .jpg, .gif, .png, or .pdf images.
Limit 20 files or 50Mb (whichever is less)
+ Add Another Receipt
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.
Please enter your SSN or 9-digit Employee No. as your signature, with no punctuation.
Change of Status
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