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State of Connecticut Medical Flexible Spending Account Claim Reimbursement Form New 10/10 EMPLOYEE ASOCIAL SECURITY CUMBERSOME ADDRESS (Check if new address)EMPLOYEE NUMBERDAYTIME PHONE NO.CITY, STATE,

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How to fill out pebb 107085-00105 fsa open

01

To fill out PEBB 107085-00105 FSA open, follow these steps:

02

Start by entering your personal information such as your name, address, and social security number.

03

Provide information about your employer, including their name and address.

04

Indicate the coverage period for the FSA open enrollment.

05

Specify the type and amount of expenses you plan to use the FSA for, such as medical or dependent care expenses.

06

Review the terms and conditions of the FSA and provide your signature.

07

Submit the completed form to the appropriate department or individual.

Who needs pebb 107085-00105 fsa open?

01

PEBB 107085-00105 FSA open is needed by individuals who are enrolled in the Public Employees Benefits Board (PEBB) program and want to take advantage of the Flexible Spending Account (FSA) open enrollment period. This form allows them to enroll and specify the amount of pre-tax dollars they wish to allocate for eligible expenses.

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What is pebb 107085-00105 fsa open?

Pebb 107085-00105 fsa open is a type of Flexible Spending Account (FSA) provided by the Public Employees Benefit Board (PEBB) program.

Who is required to file pebb 107085-00105 fsa open?

Employees enrolled in the PEBB program are required to file pebb 107085-00105 fsa open if they wish to use pre-tax dollars to pay for eligible healthcare expenses.

How to fill out pebb 107085-00105 fsa open?

To fill out pebb 107085-00105 fsa open, employees need to submit a claims form along with receipts for eligible expenses incurred.

What is the purpose of pebb 107085-00105 fsa open?

The purpose of pebb 107085-00105 fsa open is to help employees save money on healthcare expenses by allowing them to use pre-tax dollars.

What information must be reported on pebb 107085-00105 fsa open?

Employees must report details of eligible healthcare expenses incurred, along with receipts and any other required documentation.

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