Below you will find a variety of claim forms due to the different plans we have available. Please read the description of each to find the appropriate claim form for your plan. If you have a question on which form you should use please call one of our customer service representatives at 888-472-0777.

BASIC HRA debit card refund form
Click the link below to open the form used when you need to refund your employer due to an ineligible debit card charge.
Fillable PDF

BASIC HRA reimbursement forms
Click here

BASIC HRA direct deposit form
Click the link below to open the form used to request direct deposit for your BASIC HRA reimbursements
fillable PDF