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 Online Access/Account Detail tab above and then selecting Participant/Account Detail. Or, you can snap a picture of your documentation and submit via the ASIFlex mobile app.

Claim FormPDFWord
General FSA Claim FormPDFMicrosoft Word
HRA Claim FormPDFMicrosoft Word
Mass Transit/Van-Pooling/ParkingPDFMicrosoft Word
State of Arizona EmployeesPDFMicrosoft Word
State of California FlexElectPDF 
State of California Pre-Tax ParkingPDF 
North Dakota RetireesPDFMicrosoft Word
San Diego County EmployeesPDFMicrosoft Word
Iowa State University EmployeesPDFMicrosoft Word
State of Missouri EmployeesPDFMicrosoft Word
Vassar HRA Claim FormPDF