State of Indiana Retirement Medical Benefits Account Plan Claim ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Retiree Name and SSN in the designated fields. Ensure accuracy as this information is crucial for processing your claim.
3. Fill in your email address, home address, and daytime phone number. If any of these details have changed, check the box indicating a new address or contact information.
4. In the Insurance Premium Expenses section, list each dependent's name, the months covered, the provider's name (e.g., Anthem), type of insurance, and the amount of premium paid. Make sure to attach receipts from an independent third-party provider.
5. Review your entries for completeness and accuracy. Sign and date the form at the bottom to certify that all information is true and complete.
6. Submit your completed form along with all required documentation through our platform for efficient processing.

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