Veba claim form 2025

1. Click ‘Get Form’ to open the veba claim form in the editor.
2. Begin by filling out the Participant Information section. Enter your last name, first name, and participant account number or SSN. Provide your email address and check if it's new, along with your phone number and mailing address.
3. In the Out-of-Pocket Expenses and Premiums section, list all covered individuals. For each individual, provide their first name, last name, date of birth, gender, and Social Security number. Indicate their relationship to you and total out-of-pocket expenses.
4. Select the types of expenses incurred for each covered individual by checking the appropriate boxes such as medical co-pay or dental.
5. Finally, ensure you sign and date the form in the Participant Signature section. Confirm that all information is accurate and attach any required itemized verification before submitting.

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