Expense Reimbursement Form

Expense Reimbursement Request

Form to submit for reimbursement of expenses related to your surrogacy journey.
    Please explain why you incurred this expense. If you select "Other" please explain or provide more information in the comment section below. For example: compensation for confirmation of pregnancy by positive beta (or fetal heartbeat by ultrasound).
    Please identify only one type of expense at a time. You will be given an opportunity to select another type of expense later in the form.
  • How much do you need reimbursed (either in dollars or miles). Please input a number representing the amount of miles driven or the expense incurred.
  • Please identify whether you want to be reimbursed or whether you want TSEMCI to pay a third-party (like a hospital or laboratory).
    Please explain why you incurred this expense. If you select "Other" please explain or provide more information in the comment section below. For example: compensation for confirmation of pregnancy by positive beta (or fetal heartbeat by ultrasound).
    Please identify only one type of expense at a time. You will be given an opportunity to select another type of expense later in the form.
  • How much do you need reimbursed (either in dollars or miles). Please input a number representing the amount of miles driven or the expense incurred.
  • Please identify whether you want to be reimbursed or whether you want TSEMCI to pay a third-party (like a hospital or laboratory).
    Please explain why you incurred this expense. If you select "Other" please explain or provide more information in the comment section below. For example: compensation for confirmation of pregnancy by positive beta (or fetal heartbeat by ultrasound).
    Please identify only one type of expense at a time. You will be given an opportunity to select another type of expense later in the form.
  • How much do you need reimbursed (either in dollars or miles). Please input a number representing the amount of miles driven or the expense incurred.
  • Please identify whether you want to be reimbursed or whether you want TSEMCI to pay a third-party (like a hospital or laboratory).
    Please explain why you incurred this expense. If you select "Other" please explain or provide more information in the comment section below. For example: compensation for confirmation of pregnancy by positive beta (or fetal heartbeat by ultrasound).
    Please identify only one type of expense at a time. You will be given an opportunity to select another type of expense later in the form.
  • How much do you need reimbursed (either in dollars or miles). Please input a number representing the amount of miles driven or the expense incurred.
  • Please identify whether you want to be reimbursed or whether you want TSEMCI to pay a third-party (like a hospital or laboratory).
    Please explain why you incurred this expense. If you select "Other" please explain or provide more information in the comment section below. For example: compensation for confirmation of pregnancy by positive beta (or fetal heartbeat by ultrasound).
    Please identify only one type of expense at a time. You will be given an opportunity to select another type of expense later in the form.
  • How much do you need reimbursed (either in dollars or miles). Please input a number representing the amount of miles driven or the expense incurred.
  • Please identify whether you want to be reimbursed or whether you want TSEMCI to pay a third-party (like a hospital or laboratory).
  • Drop files here or
    Please attach a copy of your medical bill or other receipt evidencing the amount of the expense. Please attach a receipt or other document for every item requested on this form. Mileage will not be reimbursed without a printout of the route attached here as a receipt or included as a link below. Please also note that a red circle with an x inside it means that your file is attached. It is NOT an error message.
  • Unless provided as an attachment above, please provide a link to MapQuest evidencing the route your drove (the roundtrip route if you you drove both ways) to document mileage incurred. Mileage will not be reimbursed without a printout of the route attached as a receipt or a link provided here.
  • Please add any additional information you think TSEMCI might need in order to process your request.
    Have you provided all information TSEMCI needs in order to process your request? Forms submitted and not properly documented will not be processed and thus delay the time in which you receive your reimbursement. Please use the following checklist to ensure you are submitting a properly completed form for reimbursement of an expense.
  • Please provide your email address in case we have any questions.
  • This field is for validation purposes and should be left unchanged.