Annual Verification Benefit Claim Form – Insurance Premium Reimbursements

Expense Claim Form – Misc. Medical Reimbursements

Direct Deposit Form

Direct Deposit Instructions

Participant Data Form

Delegation of Authority to Submit Claims Form

 

PLEASE NOTE: The Annual Verification Form will be mailed on November 15, 2019; the deadline to submit all documentation to the Administrative Office is April 1, 2020. If the Information requested is not received by April 1, 2020, your monthly claims payment will be suspended.

BPA