Benefits Form"*" indicates required fieldsDate* 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.* YesAmount 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.* YesI am requesting the following date(s) as paid time off:*For example - 04/27 and 04/28Any comments?Upload Your Receipts Drop files here or Select filesMax. file size: 256 MB. PhoneThis field is for validation purposes and should be left unchanged.Δ
