Fillable CLAIM FORM FOR PREMIUM REIMBURSEMENT

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CLAIM FORM FOR PREMIUM REIMBURSEMENT

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{14091/A0666795.1}
Dr. 11/24/21
1200 Wilshire Boulevard | Fifth Floor | Los Angeles, California 90017-1906
Administered by:
Benefit Programs Administration
1200 Wilshire Boulevard, Fifth Floor
Los Angeles, CA 90017-1906
Office
: (833) 728-2747
Fax: (562) 463-5894
E-mail: centralvalley@bpabenefits.com
CLAIM FORM FOR PREMIUM REIMBURSEMENT
1)
Reimbursement Limited to Premium Paid. As a Beneficiary in the Medical Expense Reimbursement Plan
(Plan) of the
California Firefighters Benefit Trust (Trust), I understand that I am entitled to a monthly
reimbursement
benefit for insurance premiums and/or medical expense payments that I make. I
understand that the benefits paid by the Trust cannot exceed the actual premiums and medical expenses
paid by the Beneficiary. I have elected to receive reimbursement of health (medical, dental, prescription drug,
vision) insurance premiums, as stated on page two.
2)
Change in Premiums. I understand that, based on the information I provide herein, the Trust will make
payments directly to me to reimburse me for my premium payments. I agree to notify the Trust within 30
days of termination or reduction of any of the
claimed insurance premiums. If I fail to do so, I will be obligated
to reimburse the Trust for any overpayments to me, as well as to pay the Trust for penalties and
interest.
3)
Monthly Documentation of Premiums. I understand that premium reimbursement will not commence until
I have signed
this Form and returned it to the Trust Office, along with written documentation from the
insurance carrier or another third party showing:
coverage type; effective date; premium amount; and proof
of my payment of the premiums.
I also understand that I must submit this written documentation from
a third party for each month of premiums for which I request reimbursement.
The claim form is only
submitted annually, unless my premium amount changes mid-year, but documentation of premiums is
submitted for each monthly premium prior to reimbursement. I understand that I can submit the
documentation monthly or in batches, but it must be submitted before a claim for reimbursement will be paid
and it must be submitted prior to the claim deadline of April 30, 2022.
4)
Benefits May Be Adjusted. I understand that my Benefit Level is determined based upon the Unit Multiplier set
and reviewed periodically by the Trustees, and that the
Trustees may adjust the Unit Multiplier or benefit formula,
or other provisions of the Plan, from time to time, which may affect my Benefit Level.
Date of Retirement or Termination of Employment:
:_________________________
Claim Form
Premium Reimbursement
Page 2
I am enrolled in the following plan(s) with the following premiums:
Medical:
-----------------------------------
Monthly Premium
$
_
Effective Date: _
Insured Beneficiary:
Self Spouse
Child
Dental:
-----------------------------------
Monthly Premium
$
_
Effective Date: _
Insured Beneficiary:
Self Spouse
Child
Vision:
-----------------------------------
Monthly Premium
$
_
Effective Date: _
Insured Beneficiary:
Self Spouse
Child
Drug:
-----------------------------------
Monthly Premium
$
_
Effective Date: _
Insured Beneficiary:
Self Spouse
Child
Other:
-----------------------------------
Monthly Premium
$
_
Effective Date: _
Insured Beneficiary:
Self Spouse
Child
Total Monthly Premium Reimbursement Requested $____________________
5)
Income Tax Deductions. I understand that these benefit payments are not taxable, and therefore, expenses
reimbursed are not allowed as deductions when filing my individual income tax return.
6)
Premium Payment to Insurance Carrier. I understand that I am responsible for all premium payments to the
insurance carrier(s) and that the Trust
will reimburse me - not the insurance carrier.
7)
Claims Limited to Covered Expenses. If I request and receive reimbursement from the Trust for an expense
that does not qualify as a Covered Expense under Plan Section 1.10, I understand that the Trust may pursue
recoupment of overpaid benefits and penalties for failure to withhold taxes.
8)
Fraudulent Claims. I understand that the Trust may pursue legal and equitable remedies against me for any
false, fraudulent or misleading information provided, e.g. failure to advise the Trust of termination of coverage or
change in premium.
9)
Suspension of Benefits During Re-employment with Participating Employer. I affirm that I am not currently
employed by a Participating Employer (including part-time or contract work) and was not employed by a
Participating Employer when the attached expenses were incurred. I affirm that I do not intend to start employment
with a Participating Employer within the next year, and if I do, I will inform the Trust Office prior to my first day of
work.
I certify under penalty of perjury that the information I have given above is true and correct, and that I have
read this Form.
Eligible Retiree or Surviving Spouse/Child Signature Date
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CLAIM FORM FOR PREMIUM REIMBURSEMENT

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Completed 19 January 2022

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