DescriptionFlex One®/Flexible Spending Account Claim Form · Please fax this signed and completed form to: 1-877-353-9256. · For Customer Service, please call: 1-877-353-9487. 1. Participant Information and Signature By submitting this claim form, I (participant named below) request reimbursement from my Flexible Spending Account(s) as listed below. I agree to the Terms and Conditions stated below; I certify and warrant to...
Form was Filled by