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Dependent Day Care
Claim Form

To file a claim, expenses must be incurred between your effective date of coverage and March 15 of the following year. An expense is incurred when you receive the service, not when you receive the bill or make payment. The deadline for submitting claims for expenses incurred through March 15 is March 31. For expenses incurred between January 1 and March 15, any remaining balance from your prior year contributions are automatically drawn down before deductions are made against your current year contributions.

The claim form requires the following information:

  • Employee ID
  • Dates of service
  • Amount claimed for reimbursement
  • Description of the expense
  • Information on the dependent(s) for whom services were provided
  • Dependent day care provider information, including name and social security or tax ID number
  • Signature of dependent day care provider verifying receipt of payment for services
  • Your signature certifying that the expenses were incurred and qualify for reimbursement

Eligible expenses are reimbursed for the amount submitted up to the amount of your available account balance. If a claim exceeds your account balance, the excess claim amount is reimbursed as soon as your balance permits.

Claims are typically reimbursed within two weeks. If you are enrolled in payroll direct deposit, your reimbursement is deposited into that same bank account, and you receive an e-mail indicating the date the deposit was made. If you are not enrolled in payroll direct deposit, a check is mailed to your home address.

You may access your account balance and reimbursement statements at Employee Self-Service.

Employee Benefits