XXXX Complete the voucher envelope and include a receipt or statement from the dependent care provider. The receipt must show the dates of service and the name of the dependent for whom care is provided. This account is to reimburse premiums you pay for individual medical coverage for you, your spouse or eligible dependents. Life insurance premiums cannot be reimbursed through this account. You may also use this account to pay for an individual disability policy that you carry on yourself only.
Disability benefits become taxable if premiums are paid with tax-free dollars.
You may send us a copy of your policy or a copy of your bill. Please complete a voucher envelope. Your employer has a supply of voucher envelopes to be used when you have a claim to be submitted. Simply read the instructions on the front of the envelope, and if your claim is properly submitted and the expense is qualified under the plan, you will soon receive a reimbursement check. You may submit a claim any time for qualified expenses incurred during the plan year.