Printable Claim Form



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How to create a Claim Form? Download this printable Claim Form template now!

This form is to claim reimbursement for business expenses paid while conducting business on behalf of the university and for petty cash replenishments. Responsibility for complete, accurate, compliant, and properly authorized claims rests with account holders and preparers. We support you and your company by providing this sample Reimbursement Claim Form template, which will save your time, cost, and efforts and help you to reach the next level of success in your work, education, and business.

This Printable Claim Form template is intuitive, ready-to-use, and logically structured and therefore will fit your needs. The following categories are relevant when making an Expense Reimbursement Claim Form:

  • Dates of Expense(s)
  • Payment Method (Out of Pocket or by Business/Corporate Card) Purpose of Expenditure(s)
  • Please give detailed reasons for all expenditures
  • Summary of Expenses
  • Description (Date, Details, Etc.)
  • Air/Rail Travel Ground Trans Lodging
  • Meals
  • Other
  • Total
  • Expense Report 
  • Total
  • I certify these are valid business expenses.
  • Reimburse/Cardholder Signature
  • Reimburse/Cardholder 
  • Prepared by (Print)
  • I have reviewed these expenses and I believe they are true and accurate.
  • I attest that the expenses claimed are original and I certify that I have reviewed this claim and find it to be reasonable I authorize these expenses to be charged to the legitimate incurred on authorized business and have an account(s) noted and that sufficient budget exists.

Download this sample printable Claim Form template or check out other Insurance Claim templates here.




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