Employee Name ________________________________________________________________________
Last First MI
Attach a copy of the Explanation of Benefits (EOB) you receive from vision, dental and health care plans. For each attached EOB, list provider, the date of service and the amount not paid by the insurance in the CLAIM INFORMATION section. If you submitted the expense to insurance plans, attach EOB’s from both plans. If the expenses are not covered by insurance plan, attach a copy of the bill to the insurance statement denying benefit.
|
Date Incurred |
Name of Service Provider |
Person for Whom Expense Incurred |
Amount after Reimbursement |
TOTAL ________________
READ CAREFULLY:
The undersigned participants in the Plan certifies that all expenses for which reimbursement or payment is claimed by submission of this form were incurred during the period while the undersigned was covered under the Benefit Plan with respect to such expenses and that the expenses have not been reimbursed and are not reimbursable under any other insurance plan coverage. The undersigned fully understands that he or she alone is fully responsible for sufficiency, accuracy, and the veracity of all information relating to this claim which is a provided buy the undersigned, and that unless an expense for which payment or reimbursement is claimed is a proper expense under the Plan the undersigned may be liable for payment of all related taxes including federal, state, or city income tax on amounts paid from the Plan which relate to said expense.
___________________________________________________________ ____________________________
Employee Signature Date
CLAIM FILING INSTRUCTIONS
WHO CAN FILE A CLAIM FORM:
Only employees participating in the EASO Benefit Fund can file a reimbursement claim form.
Employees can file a claim form four (4) times during the plan year (March, June, September, December) All claims for a benefit year(January-December) must be filed by March 31st of the next year.
Members are encouraged to wait until they have a few EOB’s before filing.
WHAT EXPENSES CAN BE CLAIMED:
Only expenses incurred during the plan year can be claimed for reimbursement. The year of claim is the year the expense was incurred by the participant. It is imperative to send separate claim forms fro each year.
Consult your plan provider fro description of allowable expenses. An allowable expense in one that is recognized by the Internal Revenue Service as a medical/dental expense.
Members are reminded to make copies of all materials submitted. It is recommended to mail this information return receipt.
Complete all information on the reverse side and return form and all documentation to:
J.J. Stanis and Company, Inc.
100 Jericho Quadrangle
Suite 101
Jericho, New York 11753
General Phone # (516) 465-3900