Upload Your Claim

Upload a Claim to Benemax

Subscriber's Name*
Email Address*
Subscriber's Employer*
Subscriber's SS# (last 4 digits)
Patient's Name*
Type of Claim*
- Medical or Dental
- FSA
Note: A signed claim form is required for FSA Submissions.
Additional Notes
Upload Document #1
Max. file size: 2 MB.
Upload Document #2
Max. file size: 2 MB.
Upload Document #3
Max. file size: 2 MB.
Upload Document #4
Max. file size: 2 MB.
Upload Document #5
Max. file size: 2 MB.
Name
This field is for validation purposes and should be left unchanged.