{"id":50,"date":"2013-11-25T20:39:06","date_gmt":"2013-11-25T20:39:06","guid":{"rendered":"http:\/\/www.sabcflex.com\/wordpress\/?page_id=50"},"modified":"2013-11-25T20:39:06","modified_gmt":"2013-11-25T20:39:06","slug":"request-for-reimbursement","status":"publish","type":"page","link":"https:\/\/www.sabcflex.com\/content\/request-for-reimbursement","title":{"rendered":"Request for Reimbursement"},"content":{"rendered":"
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SABC<\/h1>\n

Southern Administrators & Benefit Consultants, Inc.<\/h2>\n<\/div>\n
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Request for Reimbursement<\/h1>\n
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numbers only, no hyphens<\/small><\/td>\n<\/tr>\n
() – ext.<\/td>\n<\/tr>\n
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<\/td>\nCheck here to indicate that you will pick up your reimbursement check at the
\noffices of Southern Administrators & Benefit Consultants in Ridgeland, MS.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
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<\/td>\nAn Explanation of Benefits from your insurance carrier is
\nalways the preferred receipt, and may be required.<\/td>\n<\/tr>\n
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<\/td>\nEmployer Supplement Plan (EOB Required)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
<\/td>\nIf you are submitting receipts to Validate expenses that were paid using the SABCFlex (Benny) card,
\nplease check this box<\/strong> AND scan and submit the email<\/strong> sent to you along with your receipts.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
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Attach Receipts<\/h3>\n

Please upload only .jpg, .gif, .png, or .pdf images.
\nLimit 10 files or 70Mb (whichever is less)<\/small><\/p>\n<\/div>\n\n\n\n\n
Delete<\/a><\/td>\n<\/tr>\n
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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. <\/small><\/p>\n\n\n\n\n
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<\/td>\nPlease enter your SSN or 9-digit Employee No. as your signature, with no punctuation.<\/small><\/td>\n<\/td>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
<\/div>\n<\/form>\n<\/div>\n
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