Participant forms

All participant forms can be downloaded as fillable PDFs.  If you have trouble downloading a form, contact the third-party administrator.  In most cases, you can skip the form and submit the necessary information online.  Simply log in to myHRA VEBA online. 

 


 

NOTE:  Forms are updated from time to time.  Visit this page each time you need a form to make sure you get the latest version.

 

 

 

 

 

Claim Form

Submit a Claim Form to file claims for qualified out-of-pocket expenses and premiums.  This form must be accompanied by itemized verification for each expense or service.  Claims may be submitted via e-mail, fax, or regular mail.

 

pdf   Claim Form

 

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Account Change Form

Submit an Account Change Form to update your personal account information, including investment fund selection(s), spouse and dependent information, and name and address changes.  Or, skip the form and make your updates after logging in to myHRA VEBA online.

 

NOTE:  Participant name changes require legal documentation and cannot be submitted online.

 

pdf   Account Change Form

 

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Direct Deposit Enrollment Form

Direct deposit is faster and more secure than mailing reimbursements to you via paper check.  Simply submit a completed Direct Deposit Enrollment Form to sign up.  Or, skip the form and do it online.  Login to myHRA VEBA online and click Direct deposit election.

 

pdf   Direct Deposit Enrollment Form

 

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Systematic Premium Reimbursement Form

Submit a Systematic Premium Reimbursement Form to request systematic reimbursement of your ongoing insurance premiums.  Or, skip the form and do it online.  Login to myHRA VEBA online and click Systematic premium reimbursement.

 

pdf   Systematic Premium Reimbursement Form

 

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Notice of COBRA Qualifying Event

Submit a Notice of COBRA Qualifying Event when either of the following events occur:  (1) divorce or legal separation; or (2) qualifying child no longer meets the definition of dependent.  COBRA qualified beneficiaries have a right to elect continued coverage for up to 36 months.  To learn more, read the COBRA Notice inside the Plan Summary.

 

NOTE:  Carefully follow the Notification Procedures on the back side of the form.  To be valid, notice must be fully completed, signed, and received by the third-party administrator (TPA) no later than 60 days after the qualifying event. If your notice is late, incomplete, or is not submitted as instructed, no qualified beneficiary will be offered COBRA continuation coverage.

 

pdf   Notice of COBRA Qualifying Event form

 

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Election of Limited VEBA Plan Coverage

Submit an Election of Limited HRA VEBA Plan Coverage form if you want to become eligible to make contributions to a health savings account (HSA).  Or, skip the form and do it online.  Login to myHRA VEBA online and click Account preferences.

 

NOTE:  Limiting your VEBA Plan coverage is not the only requirement to become eligible to make contributions to an HSA.  Go to HSA contribution eligibility to learn more.

 

pdf   Election of Limited VEBA Plan Coverage form

 

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