Acme South Only: Tri-State Excepted Benefit Health Reimbursement Account (HRA) Claim Form

Excepted Benefit Health Reimbursement Account (HRA) Claim Form Mail, fax or email completed form and documentation to: 27 Roland Avenue, Suite 100, Mt. Laurel, NJ 08054

Fax: 856-793-3100

Email: aramirez@tsonline.com

1. Please print clearly.

2. All information in each section must be completed.

3. Attach required documents. Refer to eligible expenses on the reverse side of this form. The participant must sign each Claim Form that is submitted. Reimbursement will not be processed without a signed form.

4. All receipts must be for services after 5/1/2025.

Eligibility Requirements, are for all active full-time employees and all active part-time employees of Acme South with eighteen (18) months of service.

Tri-State Excepted Benefit Health Reimbursement Account (HRA) Claim Form.pdf

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