Southern Administrators & Benefit Consultants, Inc.

Debit Card Expense Validation Form

(Submit separate request forms for each plan year.)
numbers only, no hyphens
 Employee Name will automatically populate based on employee id.

Company Name will automatically populate based on employee id.
() - ext.

Check here to indicate that you will pick up your reimbursement check at the
offices of Southern Administrators & Benefit Consultants in Ridgeland, MS.

An Explanation of Benefits from your insurance carrier is
always the preferred receipt, and may be required.
Employer Supplement Plan (EOB Required)

Attach Receipts

Please upload only .jpg, .gif, .png, or .pdf images.
Limit 20 files and 8mb per file attachment!


Claim Comments:

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.
Signed Date: 2019-02-19
Please enter your SSN or 9-digit Employee No. as your signature, with no punctuation.