On the left-hand side of the Health Reimbursement Arrangement (HRA) landing page you will see the letters “HRA.” Under those letters you will see the following “HRA Claim Form.” Click on “HRA Claim Form.”
Print out the HRA Claim Form and commence to completing it in its entirety. Fill out all the fields AND sign and date the document. If you need more space, download another form and completely fill out that form.
If you are submitting a manual claim form for a shortage of hours, under the “Date of Service” you would list two dates. The first date would be the opening date of the work quarter in which the shortage occurred, and the second date would be the last day of the work quarter in which the shortage occurred. If you neither recognize the term “work quarter” nor know what work quarter you incurred a shortage of hours, please reference the eligibility section of the Plan’s Summary Plan Description book.
Make a copy of your properly completed, signed and dated form and all supporting documentation and keep for your records.
You can either mail your properly completed, signed and dated HRA Claim form and supporting documentation to:
PO Box 161357
Altamonte Springs, FL 32716
Or fax the properly completed form and supporting documentation to:
844-791-8317 or 978-856-6612
Self-payments and/or shortage of hours payments that arrive at the Fund office after the date that they are due, will not be accepted. As such, make certain to mail your shortage of hours and/or self-payment at least fourteen or more calendar days ahead of when the payment is due. Make sure that you account for any holiday, or anything else that would cause a delay in the delivery of your request and act accordingly to mitigate that risk.