Download and Print Forms Here

Use the following forms only if you are unable to submit online.

Remember, it's easy to log in to your online account portal to establish a Recurring Premium Reimbursement request, submit a One-Time Reimbursement request, or enroll in Direct Deposit.

If you would prefer to submit a reimbursement request by mail or fax, download, print and complete the appropriate claim forms below and provide the supporting documentation required for each claim. If you would prefer to enroll in Direct Deposit by mail, download, print and complete the form below. You should make a copy of all forms you submit so you can retain the originals for your records. 

As a reminder, there are no forms to complete for an Automatic Premium Reimbursement; you may establish your Automatic Premium Reimbursement by phone with the help of a benefits counselor.

Please refer to your Reimbursement Instructional Guide for additional information.