Accountable Value Financial Services: Claim Form Submission

Online Claim Form Submission

Claim Form 2025

Our claim form is changing. If your submission does not go through, please either try again or reach out for an alternative method.

Company Name(Required)

Please enter the name of your company

Covered Employee Name(Required)

Please enter the name of the covered employee.

First Last

Covered Employee Email(Required)

Claim Date(Required)

Please enter the date of the claim

Claim Details

Please fill out the details of your claim. You can choose from: Dental; Prescription; Optometry; Massage; Chiropractic. You can total up each category and have 1 entry rather than multiple ones. The maximum file size is 10mb per file. If you exceed that, please upload multiple files or a smaller file. Click on the plus icon to add another expense to this claim. Max total file size is 2047MB

Receipt Information(Required)

Please include the name of the file you are uploading.

Expense Type

Amount

Filename

Receipts(Required)

Please upload all your receipts. You may upload more than one file at a time.

Drop files here or

Accepted file types: jpg, jpeg, pdf, gif, png, bmp, tif, xls, xlsx, Max. file size: 2 GB.

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