Checklist for Turning in Your Flexible Spending Account (FSA) Claim

• Include your name, Social Security number, mailing address, & telephone number on a request for reimbursement form.
• Itemize your expenses & dollar amount for each receipt attached
• Attach all Explanation of Benefits (EOB's) and/or receipts for each item requested
• Total the charges and list the amount of reimbursement you are requesting
• Sign and date your reimbursement form
• Mail your completed reimbursement form and your documentation to Principal Financial Group, Central Mail Facility, PO Box 39710, Colorado Springs CO 80949-3910.

Important Reminders

• Balance Due statements, cancelled checks and credit card receipts are not valid for reimbursement.
• We can only reimburse charges that have been incurred. Any charges for future dates of service can not be reimbursed until the services have been provided, even if the charges have already been billed or paid.

Helpful Hints and General Guidelines

• When submitting multiple receipts, it is helpful to only submit one reimbursement form provided that all the receipts can be itemized on the back of one form. If you are submitting claims for two plan years, separate the receipts and reimbursement form by plan year. This will speed up the processing of your claims.
• If you are submitting several receipts it is a good idea to tape them down to a larger piece of paper to be certain they stay attached to the reimbursement form. We recommend making copies for your records.

Health Care Reimbursement

• When submitting a claim that has been paid partially by your medical, dental, and/or vision insurance attach a copy of the EOB.
• When submitting a claim that is not covered by your medical, dental, and/or vision insurance attach a copy of a receipt that includes the following:
  • Dates of service
  • Provider's name
  • Procedures and dollar amounts
• If you are requesting reimbursement for a prescription copay attach a copy of a print out from the pharmacy, or the individual receipts showing patient name, the name of the prescription, date of service and the amount that you are responsible for.

Dependent Care Reimbursement

• If your daycare charges are for services provided by an in-home daycare provider, your receipt must contain the following information:
  • Provider name
  • Dates of service and children's names
  • Amount of the charges for the dates of service listed
  • Provider signature
• If your daycare charges are from a daycare center the center will usually provide you with a receipt on their letterhead. The same information is required on the receipt that an in-home daycare provider must provide, except a signature is not necessary.

When you submit your daycare charges for reimbursement, we will automatically hold any charges over the balance in your account to the next paydate for reimbursement provided funds are available.

If you do not want your remaining charges over the account balance held for future reimbursement and only want to be reimbursed for what has been withheld from your check, clearly mark this on your reimbursement form under the amount requested column.

If you have any questions regarding any of the above information, please contact your Service Center at the phone number listed on your reimbursement form. You can also log on to www.principal.com 24 hours a day and check the status of your FSA claims and balances by choosing the Personal Login option.

GP 48295 03/2001