Get Annual Recurring Premium Reimbursement Claim Form

This guide provides step-by-step instructions on completing the Annual Recurring Premium Reimbursement Claim Form online. By following these directions, users can efficiently submit their claims for healthcare premium reimbursements.

Follow the steps to complete your claim form accurately.

1. Click ‘Get Form’ button to access the Annual Recurring Premium Reimbursement Claim Form and open it for editing.
2. Begin with the Account Holder Information section. Fill in the Account Holder's last name, first name, middle initial, Social Security number, and zip code.
3. Proceed to the Covered Participant Information section. Enter the covered participant's last name, first name, middle initial, Social Security number, and their relation to the Account Holder.
4. In the Reimbursement Request Information section, determine if this is a new claim, a change in premium, or an end of the policy, and select the appropriate option.
5. Specify the type of premium you are claiming (e.g., medical) in the corresponding field.
6. Enter the Begin Date for the premium, which is typically January 1st, or the effective date of coverage.
7. Fill out the End Date for the premium, generally December 31st, unless there is a policy change.
8. Complete the Monthly Amount field with the amount you are requesting reimbursements for.
9. Read the Certification Requirement carefully, ensuring you understand the stipulations before signing. Enter your signature and the date to certify the accuracy of the information provided.
10. After filling out all fields, save your changes. You may choose to download, print, or share the completed form as needed.

Start completing your Annual Recurring Premium Reimbursement Claim Form online today.