Get Recurring Premium Reimbursement Request Form - Pebp State Nv

This guide provides clear instructions on how to complete the Recurring Premium Reimbursement Request Form for Pebp State Nv online. By following these steps, users can ensure a smooth submission process for their reimbursement requests.

Follow the steps to successfully complete your reimbursement request form.

1. Click the ‘Get Form’ button to acquire the form and open it in your chosen editor.
2. In the first section labeled 'Account Holder Information', fill out the employer name, account holder's information including their last name, first name, middle name, social security number, and zip code.
3. Proceed to the 'Reimbursement Request Information'. Select the action you are taking: 'New', 'Premium Change', or 'End of Policy'. Fill in the relationship of the person requesting the premium reimbursement to the account holder.
4. Specify the type of premium by selecting from the options provided: Medicare Part B, Medicare Part C (Advantage), Medicare Part D, Medicare Supplement (Medigap), Dental, or Vision Prescription.
5. Indicate the start date and end date for the coverage. The start date usually begins on January 1st, while the end date is typically December 31st, unless specified otherwise.
6. Enter the monthly amount you are requesting, ensuring it matches the figure on your supporting documentation.
7. In the 'Certification Requirement' section, read the requirements thoroughly. Sign and date the form, confirming that all provided information is accurate and complies with the stated conditions.
8. Ensure that you have attached the correct supporting documentation as outlined in the form, which may include third-party documentation confirming details such as the covered participant's name, premium amount, and coverage description.
9. Once all fields are completed and documentation attached, you may save changes, download, print, or share the completed form as necessary for your submission.

Complete your form online today to ensure timely reimbursement for your premiums.