Via benefits reimbursement form 2022-2026

1. Click ‘Get Form’ to open it in the editor.
2. Complete the Account Holder fields: Enter your full name, last four digits of your Social Security number, date of birth (MM/DD/YYYY), address, and employer name.
3. Under Insurance Premium Expenses, fill in the Name of Covered Individual, select the appropriate Action (New Policy, Premium Change, or End of Policy), and specify the Type of Premium you wish to be reimbursed.
4. If applicable, provide the Annual Social Security Administration Letter. Enter the Beginning and Ending Dates of Service for your reimbursement period.
5. Input the Monthly Amount Requested that matches your supporting documentation.
6. Read through the certification requirements carefully before signing and dating the form.
7. Mail or fax your completed form along with any necessary supporting documentation to PayFlex as instructed.

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