Reimbursement Request

Request for Reimbursement

Employee Name *

First

Last

Employee Phone Number *

Employee Email *

Company Name *

New Address? *

Line 1

Line 2

City

State

Zip Code

Country

Reimbursement Requested

Please list eligible medical, dental, vision services and/or expenses for you and your dependents that you have not already claimed through Polestar Benefits, Inc. in the appropriate fields below. Only list the amount of the expense you are eligible for and is not being reimbursed through another Plan or by another Administrator / Carrier.

1a) Service *

1b) Plan *

1c) Estimated $ *

2a) Service *

2b) Plan *

2c) Estimated $ *

3a) Service *

3b) Plan *

3c) Estimated $ *

4a) Service *

4b) Plan *

4c) Estimated $ *

Comments *

You must submit independent, 3rd party documentation of your expenses with this request. If any of these expenses were covered by insurance, attach a copy of the "Explanation of Benefits" from your insurance company as documentation.

Supporting documentation must include:
    • Date of Service / Purchase
    • Type of Service / Purchase
    • Patient Name
    • Amount of Service / Purchase

Upload Supporting Documentation *

Max file size: 10MB

Upload Additional Supporting Documentation *

Max file size: 10MB

Upload Additional Supporting Documentation *

Max file size: 10MB

By clicking submit, I certify that these statements are true and that the claimed expenses were incurred to diagnose, cure, treat, mitigate, and/or prevent a disease and cover only myself, my tax dependents, and/or spouse (if filing taxes jointly). I understand that items purchased merely to promote general health are not reimbursable. I further understand that expenses reimbursed by Polestar Benefits, Inc. may not be claims on my individual tax return at the end of the year.

Submit

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