Benefits Form "*" indicates required fields Date* MM slash DD slash YYYY Your Name* First Last What is this request for?*Choose OneHealth Spending Account (HSA)Office Spending Account (OSA)Paid Time OffWhat is this HSA request for?*Choose OneEye exam and/or glasses/contactsDentalChiropracticNaturheil Zentrum Oliver Weiss ClinicWhat is this OSA request for?* Is this an Advancement or a Reimbursement?* Advancement (You are asking for the money in advance of paying for the service or item.) Reimbursement (You already paid for the service or item and have a receipt.) I understand for an Advancement I still need to send a receipt once I have paid for the service.* Yes Amount you are requesting reimbursed or advanced in U.S. dollars:*Currency Converter: https://www.xe.com/currencyconverter/convert/?Amount=1&From=PHP&To=USDI understand that this money is to be used only for myself and for the approved categories listed in AIB's benefit policy documents.* Yes I am requesting the following date(s) as paid time off:*For example - 04/27 and 04/28 Any comments?Upload Your Receipts Drop files here or Select files Max. file size: 256 MB. EmailThis field is for validation purposes and should be left unchanged. Δ