Claim Forms

Before you submit a claim, review page 1 of the claim form, “How to Submit Claims.” You can also submit claims online by clicking the Employee Login above. You can also snap a picture of your documentation and submit via the ASIFlex mobile app.

Documentation Needed
Documentation Needed
Claim FormPDFWord
General FSA Claim FormPDFMicrosoft Word
Dependent Care Automatic Claim Request FormPDFMicrosoft Word
HRA Claim FormPDFMicrosoft Word
JCCC Retiree HRA Claim FormPDFMicrosoft Word
Lincoln Electric WSA FormPDF 
Mass Transit/Van-Pooling/ParkingPDFMicrosoft Word
New Hampshire LSA FormPDF 
North Dakota RetireesPDFMicrosoft Word
SD County Employees Retirement Assoc_SDCERAPDFMicrosoft Word
State of Missouri EmployeesPDFMicrosoft Word
Vassar HRA Claim FormPDF