Accountable Value Financial Services: Online Claim Submission

Online Claim Form Submission

Online Claim Form

Use this form when submitting a claim online! Your information will be transmitted securely. Your attachments will be purged from our servers once the claim has been submitted. Your information will NOT be stored in our online databases.

Company Name*
Please enter the name of your company
Covered Employee Name*
Please enter the name of the covered employee.
First Last
Claim Date*
Please enter the date of the claim
Date Format: MM slash DD slash YYYY
Employee's Email
Please enter the employee's email
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.
Expense Type Expense Amount Receipt Upload
Claim Notes
Any special requests or instructions.
Name
This field is for validation purposes and should be left unchanged.

Expense Type	Expense Amount	Receipt Upload