Benefit Trust Claim form

Pay Me Back Claim Form

VCPFA Benefit Trust
Beneficiary Info*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claim for out-of-pocket expenses

Complete each page by quarter
Year*
Year of benefits on claim
Quarter*

1 - Jan, Feb, Mar2 - Apr, May, Jun3 - July, Aug, Sep4 - Oct, Nov, Dec

Expense type - (expenses by month for the quarter selected)*

	Month of Coverage	Expense Type	Amount
1
2
3
4
5
6

Year
Year of benefits on claim
Quarter

1 - Jan, Feb, Mar2 - Apr, May, Jun3 - July, Aug, Sep4 - Oct, Nov, Dec

Expense type - (expenses by month for the quarter selected)*

	Month of Coverage	Expense Type	Amount
1
2
3
4
5
6

Attach proof of medical premiums (invoices, statements, etc.)*

Browse Files

Cancelof
I certify that the information on this form is accurate and complete. I am requesting reimbursement for eligible deductible expenses incurred by myself or an eligible dependent while I was a participant in the plan.
Claimant's Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: