SABC Southern Administrators & Benefit Consultants, Inc. Request for Reimbursement Plan Year: to (Submit separate request forms for each plan year.) Company Name: Employee Name: SSN (or 9-digit Employee No.): numbers only, no hyphens Daytime Phone: () – ext. Email Address: 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. Premium Reimbursement Expenses Total: HRA Expenses Total: Employer Supplement Plan (EOB Required) Validation: If you are submitting receipts to Validate expenses that were paid using the SABCFlex (Benny) card, please check this box AND scan and submit the email sent to you along with your receipts. Attach Receipts Please upload only .jpg, .gif, .png, or .pdf images. Limit 10 files or 70Mb (whichever is less) Receipt Image: Delete 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. Signature: Date: Please enter your SSN or 9-digit Employee No. as your signature, with no punctuation.