Indiana security benefit 2026

1. Click ‘Get Form’ to open the Indiana Security Benefit Reimbursement Claim Form in the editor.
2. Begin by providing your personal information in Section 1. Fill in your Employer Group Name, Social Security Number, and contact details. Ensure all fields are completed accurately.
3. In Section 2, detail your insurance premium reimbursement request. Include the policy holder's name, description of the policy, and the amount you wish to be reimbursed. Make sure to specify the frequency of payment.
4. For medical reimbursements in Section 3, select your preferred payment method—either direct deposit or check. If opting for direct deposit, provide your bank account details.
5. In Section 4, sign and date the form to confirm that you understand the requirements for reimbursement and that all claims are valid.
6. Finally, summarize itemized medical bills in Section 5. List each service with corresponding dates and amounts requested for reimbursement.

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