Fillable Claim Form Veba Trust printable pdf download

Claim Form

Skip this form! Log in at and submit your expenses and documentation online.

Read instructions and helpful information on reverse. Use a separate form for each covered individual.

Submit completed form to:

claims@ | Fax: (206) 577-3020 | VEBA Plan, PO Box 80587, Seattle, WA 98108

PARTICIPANT ACCOUNT and CONTACT INFORMATION

If you have more than one claims-eligible account, enter the participant account number of the account from which you want to be reimbursed. Otherwise,

your claim will be reimbursed from the account with the earliest claims-eligibility date.

Have you previously separated or retired from the

employer that made/is making contributions to this

account?

ACCOUNT NUMBER or SSN

DATE OF BIRTH

MM / DD / YYYY

YES

DATE OF SEPARATION OR RETIREMENT

MM / DD / YYYY

LAST NAME

EMPLOYER NAME

FIRST NAME

M.I.

Check here if your phone number, email, or mailing address has changed.

E-Communication:

Please provide updates below:

Please check the box and

enter your email address

in the update box at the

left to receive statements,

AREA CODE and PHONE NUMBER

EMAIL ADDRESS (use home or personal email address)

newsletters, EOBs, and

notices electronically. Read

details on reverse.

MAILING ADDRESS

CITY

STATE

ZIP

REQUIRED PARTICIPANT SIGNATURE and CERTIFICATION

I hereby certify that (1) the information provided in this claim request is true and correct; (2) the amount of this submitted claim is an accurate statement of my

(a) unreimbursed medical/dental/vision expenses after payment by insurance (if any) and/or (b) medical/dental/vision/tax-qualified long-term care insurance

premiums; and (3) the submitted claim is not reimbursable from any other source. With respect to claims submitted on behalf of qualified dependents, I hereby

certify that such person meets the Plan requirements as summarized on the reverse and is a qualified dependent as defined under the terms of the Plan. With

respect to claims for qualified insurance premiums, I hereby certify that such premiums have not been paid by an employer, and are not eligible for pre-tax

deduction through my employer’s section 125 cafeteria plan. I acknowledge and agree that any claim submitted fraudulently could result in my termination from

the Plan and/or other legal action.

Post-separation HRA Plan Participants Required Certification: If this claim is to be reimbursed from a Post-separation HRA Plan account,

check the box to certify that you were not employed (or re-employed) by the employer that made or is making contributions to your account

on the date any of the following medical care expenses were incurred. Failure to provide this required certification will cause your claim

reimbursement to be delayed or denied.

PARTICIPANT SIGNATURE

DATE

PHONE NUMBER WHERE I CAN BE REACHED

MM / DD / YYYY

PATIENT INFORMATION (covered individual)

This claim is for:

c Myself

c Qualifying Child

This informaTion is required by federal law:

(choose one)

c Legal spouse c Qualifying Relative

YES

Is this person currently, or have they ever

c Other:

___________________________________

been, enrolled in Medicare Part A or Part B?

LAST NAME

NAME EXACTLY AS IT APPEARS ON SOCIAL SECURITY CARD or MEDICARE CARD

FIRST NAME

M.I.

c Male

MEDICARE ID NUMBER (HICN)

PART A

PART B

c Female

EFFECTIVE DATE

DATE OF BIRTH

SOCIAL SECURITY NUMBER

MM / DD / YYYY

REIMBURSEMENT REQUEST FOR QUALIFIED OUT-OF-POCKET EXPENSES

REMINDER: You must include proof of each expense (e.g. Explanation of Benefits (EOB), detailed receipts, etc.). Claims for employee-paid premiums

deducted after tax require a letter from the employer confirming that no pre-tax option exists.

DATE OF SERVICE

SERVICE PROVIDER or ITEM PURCHASED FROM

TYPE OF SERVICE or ITEM (Office visit, Rx, Dental, etc.)

AMOUNT YOU PAID

HAVE MORE EXPENSES?

Include an itemized list on a separate sheet of paper.

Please add up your expenses to verify the total.

Total Reimbursement Request

QUESTIONS?

Important information and helpful tips on reverse

1-888-828-4953 | customercare@ |

VP01 (12/14 PRC)

Claim Form Veba Trust

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