https://apps.myapps.paychex.com/fsa_emp/do/claims/submit/new
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Submit New Claim |
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Confirmation - 8438097
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Branch/Client
- 0087/A8740207
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| Claim Details |
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Current Date:
03/12/2013
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Plan
Type |
Relationship |
Service
Date |
Description |
Claim Amount |
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UME |
Spouse |
02/25/2013 |
Dental |
$1,033.10 |
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Total |
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$1,033.10 |
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To complete your claim submission, print this page and attach copies of your itemized receipts. Fax the information to (585) 389-7003 or mail it to the following address:
Paychex, Inc.
Attn: Section 125 Department
box 3000
Henrietta, NY 14467-3000
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| The information contained herein is true and correct. The expenses incurred were for myself, my spouse as defined by federal law, or my eligible dependent(s) and these expenses are not reimbursable under any other source. |
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