Get Request For Insurance Premium Refund (.pdf)

Filling out the Request For Insurance Premium Refund form online can streamline your process to obtain a refund for any overpaid premiums. This guide provides clear, step-by-step instructions to complete the form accurately and efficiently.

Follow the steps to fill out your refund request form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the entity name in the designated field to identify the organization that is requesting the refund.
3. Fill in the group or division number in the corresponding space to ensure proper identification within the entity.
4. Provide the entity's address in the designated area to facilitate accurate communication regarding the refund.
5. Input the employee’s name and member ID or Social Security number in the respective fields to associate the refund with the specific employee.
6. Record the month and year of the premium payment to specify the period during which the overpayment occurred.
7. Enter the monthly premium paid and the monthly premium due in the corresponding fields to calculate any overpayment.
8. Automatically calculate the refund due by assessing the difference between the monthly premium paid and the monthly premium due.
9. Indicate the total refund amount to ensure clarity on the requested refund.
10. Provide a clear reason for the overpayment in the specified section to facilitate the review process.
11. Obtain the signature of the insurance coordinator in the designated field and date it to validate the request.
12. Once all sections are complete, review the form for accuracy before saving your changes, downloading, printing, or sharing the document as necessary.

Start filling out your Request For Insurance Premium Refund form online now to expedite your refund process.