Rocky Mountain Claim Form PDF Details

Do you have an insurance policy in the Rocky Mountain area? If so, it's important to understand the process of filing a claim. In this blog post we'll cover everything you need to know regarding Rocky Mountain claim forms and how filling one out correctly can ensure that your claims are quickly and accurately processed. We'll go over details such as what type of information needs to be provided in the form, helpful tips on getting reliable estimates for repair costs, and ultimately, how submissions with complete documentation will help make sure that your claims process is smooth sailing. Read on if you want more insight into understanding Rocky Mountain claim forms!

QuestionAnswer
Form NameRocky Mountain Claim Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesrockymountainreserve com, rocky mountain reserve fsa login, rocky mountain spotted fever forms for disability to be off work, forms

Form Preview Example

All expenses for which reimbursement or payment is claimed by submission of this form were incurred during a period while the undersigned was covered under the Company's Flexible Spending Account with respect to such expenses.
All expenses were incurred (service provided) in the Plan Year indicated above. Both medical expenses and/or dependent care expenses are “qualifying” expenses.
Medical expenses have not been reimbursed or are not reimbursable under any other health plan coverage.
The undersigned fully understands that he or she alone is fully responsible for the sufficiency, accuracy, and veracity of all information provided by the undersigned, and
that unless an expense for which payment or reimbursement is claimed is a proper expense under the Plan, the undersigned may be liable for payment of all related taxes including federal, state, or city income tax on amounts paid from the Plan which relate to such expense.
Rocky Mountain Reserve is a mere claims paying agent of the employer. All reimbursements are paid out of the general assets of the employer. There is no separate fund or account for the plan. There is no separate fund or account that secures Cafeteria Plan benefits.

CLAI M FORM

PO Box 631458 Littleton, CO 80163

P:(888) 722-1223 F: (866) 557-0109 claims@rmrbenefits.com www.RockyMountainReserve.com

Name:

Employer:

 

Email Address

 

 

 

SSN

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

Dayt ime Phone Number

 

PLAN YEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Care Expenses

Accounts: FSA = Flexible Spending Account, HRA = Health Reimbursement Arrangement, OIP = Outside Insurance Premium Account, PKG = Qualified Parking Account, TRN = Qualified Transportation Account

Date of Service

Account

Type of Service

Patient

Amount

Dependent Care Expenses

 

 

 

TOTAL CLAIMS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Service

 

Dependent Name

 

 

Amount

 

 

From:

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Daycare Provider Information:

TOTAL CLAIMS:

Name: _____________________________________________ Provider Signature:_________________________________________

(Provider name and signature is only required in the absence of a receipt from the daycare provider)

The undersigned participant in the Plan certifies the following:













A copy of a third party receipt, bill or statement showing an amount and proof of service (not just payment) must be included in order to process this claim.

Employee Signature

Date

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