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Filling out the Inland Empire Electrical Workers Supplemental Benefits Account claim form can be a straightforward process when you follow the right steps. This guide aims to provide clear instructions to help you complete the form efficiently.

Follow the steps to fill out your claim form accurately

1. Press the ‘Get Form’ button to access the claim form and open it for editing.
2. Begin by entering your personal information. This includes your name, account ID or Social Security number, date of birth, and state of residence. If any of this information is new, check the designated box.
3. Input your mailing address, including city, zip code, email address, and phone number. Ensure to check the box if this information has changed.
4. In Section A, fill out the reimbursement request details. Provide the date of service, name of the service provider, a description of the expense, the person incurring the expense along with their Social Security number and date of birth, and the total amount incurred.
5. In Section B, complete the insurance premium reimbursement request by entering the insurance company's name, the monthly premium amount, the number of months paid, and the total amount.
6. Review the total amount of reimbursement for both sections to ensure accuracy. If your account does not have sufficient funds, check the box to authorize the administrator to use future contributions for the remainder.
7. Sign and date the form to certify that all provided information is accurate. Ensure you read through the certification to confirm eligibility for all claims submitted.
8. After completing the form, save the changes, and then you have the option to download, print, or share the claim form as necessary.

Complete your claim form online today to access your benefits efficiently.