You may fill in and/or print any of the forms below for your use and distribution. You will need Adobe Acrobat Reader in order to view, fill in and print these forms. You may also contact the HRA VEBA third-party administrator for a supply of forms and/or contact your benefits department.

 HRA VEBA Membership Enrollment Kit

• Description of Plan Benefits and Membership Enrollment Form (PDF)
• Investment Fund Information (PDF)
• Spouse / Dependent Information (PDF) 

Statement of Claim for Medical/Dental/Vision Expenses or Premiums (PDF)

Systematic Payment Form (PDF)

Account Information/Fund Allocation Change Form (PDF)

Direct Deposit Enrollment Form - if you want to make direct deposit
      effective on your account, please complete this form and mail or fax to
      the third-party administrator's office listed on the form (PDF)

 E-statement Sign Up Form - complete this form if you want to receive your
      periodic participant activity statements via e-mail. (PDF)

 Summary of Benefits (PDF)

 Qualified Expenses & Premiums (PDF)

You must have Adobe Acrobat Reader installed on your system to read the PDF files above. Click the link above to download your free copy.