Get Diversified Benefit Services

This guide provides clear and detailed instructions on how to complete the Diversified Benefit Services online form. Follow the steps outlined below to ensure accurate and efficient submission.

Follow the steps to fill out the form correctly

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your employee name in the designated space. Ensure to print clearly for legibility.
3. In the Participant ID Number section, provide the last four digits of your Social Security Number for identification.
4. Next, include your email address or Social Security Number, depending on which is applicable.
5. Indicate any changes to your address or information clearly to keep your records updated.
6. In the Name of Your Employer section, please print the name of the organization you are employed by.
7. Sign the form where indicated and include the date of your signature. This certifies your request.
8. In the Amount of reimbursement requested section, enter the dollar amount you are seeking for reimbursement.
9. Indicate who incurred the expense by checking all applicable boxes: Employee, Spouse, or Dependent.
10. Attach any required documentation, such as an Explanation of Benefits report, that supports your reimbursement request.
11. Review all entries for accuracy before final submission.
12. Save your changes, and choose to download, print, or share the completed form as needed.

Take action now by completing your Diversified Benefit Services document online.