| Flexible Spending / Reimbursement Forms |
- Credit Authorization Form
Needs to be completed for all participants enrolled in their employers Flexible Spending, Dependent Care & Transportation Plans that wish to receive their reimbursements directly deposited into an account of their choice. No more checks, no more going to the bank, Direct Deposit is a great convenience. All completed Credit Authorization Forms should be mailed to the attention of: Flexible Spending
return to top
|
|
- Flexible Spending Forms
For those participants enrolled in their employer's Flexible Spending Account (FSA) Plan and wish to receive reimbursement for expenses and services.
- Orthodontic Claims Instructions
Before filing Orthodontic Claims for reimbursement from your Flexible Spending Account (FSA) please read these instructions.
- Flexible Spending Orthodontic Reimbursement Form
For those participants enrolled in their employer's Flexible Spending Account (FSA) plan and wish to receive automatic monthly reimbursement for Orthodontic expenses and services.
return to top
|
| Dependent Care |
- Dependent Care Reimbursement Claim Form
Used for participants enrolled in their employers Dependent Care Reimbursement Plan and wishes to receive reimbursement for expenses and services.
- Automatic Dependent Care Reimbursement Claim Form
Used when participants enrolled in their employers Dependent Care Reimbursement Plan wish to receive automatic payment from their account for dependent care that is provided on regular basis and the cost of that care is consistent through out the plan year.
return to top
|
| Transportation |
return to top
|
Miscellaneous |
|
| Dental |
return to top
|
| Disability |
- Proof of Disability Form
To be completed by all participants who are currently out on Short-Term Disability and SOMI is the Administrator of their Short-Term Disability Plan. If have you questions relating to the completion of this form please contact us via email at customerservice@somi.com or visit our contact page for more options.
return to top |
