Follow the steps to complete your reimbursement claim form online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Provide your personal information in Section 1. This includes your employer group name, social security number, name, mailing address, date of birth, and contact information. Make sure to indicate if your address has changed.
3. In Section 2, detail your insurance premium reimbursement. Include the policy holder's name, the description of the policy (e.g., medical or dental), policy period, reimbursement start and end dates, the amount requested, frequency of reimbursement, and where the payment should be sent.
4. Proceed to Section 3 to select the payment method. Choose either direct deposit or check payment, and ensure that you provide all necessary bank information if opting for direct deposit.
5. Complete Section 4 by providing your signature and the date. This confirms that your claim represents valid medical expenses and that you are eligible for reimbursement.
6. In Section 5, summarize your itemized medical bills. For each item, list the participant or qualified IRS dependent's relationship, description of service, date of service, and amount requested.
7. Review all sections thoroughly to ensure accuracy. After filling in the required fields, save your changes. You can then download, print, or share the completed form as necessary.

Start your reimbursement claim process by completing the IN Security Benefit 32-90250-02 online today.