Online Claim 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 companyCovered Employee Name*Please enter the name of the covered employee. First Last Claim Date*Please enter the date of the claim Employee's EmailPlease 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 TypeExpense AmountReceipt Upload Claim NotesAny special requests or instructions.NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms. Share this:TwitterFacebookLike this:Like Loading...