Wilson-McShane Corporation
Attn: National Roofers Union & Employers Joint Health & Welfare Fund Claims Department
3001 Metro Drive - Suite 500 • Bloomington, MN 55425
Phone: (952) 854-0795 Toll Free: (800) 622-8780
Fax: (952) 854-1632
(Must be submitted within twelve months of the date on which the expense was incurred in order to be eligible for reimbursement)
Please attach the Explanation of Benets (EOB) in the order you have it listed below and ll in with dates of service, description, and claim total, then sign and date below and
mail or fax to Wilson-McShane Corporation, Attn: National Roofers Union & Employers Joint Health & Welfare Fund Claims Department.
Please attach documentation to the back of this form
Please make copies of this form for future use
Name: __________________________________________________________ SS No: __________________________
Address: _________________________________________________________________________________________
City: _______________________________________ State: ______________ Zip Code: _________________________
ID No.: _____________________________________________ Phone No.: (_________) _________________________
E-mail Address:____________________________________________________________________________________
Please select the type(s) of refund you are utilizing, and then ll in all areas of that section.
1. Self Payment / Retiree Payment Reimbursements Please ll month(s) of refund and dollar amount(s).
2. Deductible, Coinsurance & other Eligible Reimbursements
This is to certify that my statements on this Claim Form are complete and true. I am claiming reimbursement only for eligible expenses incurred during the applicable
plan year and for my eligible dependents. I certify that these expenses have not been, nor will be reimbursed under this or any other benet plan and will not be claimed
as an income tax deduction. I authorize my HRA account to be reduced by the amount requested.
Signature:_______________________________________________ Date:_______________________________
Reminders: Sign and date the Reimbursement Form. Wilson-McShane Corporation cannot process an unsigned form.
Provide an EOB(s) for all expenses submitted. / Keep copies of everything submitted. / Minimum check amount is $25.00.
Cancelled checks or credit card receipts/statements or Provider statements are not valid forms of documentation.
IRS guidelines require that Wilson-McShane Corporation keeps records of all claims and correspondence for three years.
Multiple expenses may be included on one form. If more space is needed, attach additional forms.
Mail completed forms to:
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$
$
$
Claim Total:
All valid forms of documentation must include the following: Date(s) of Service, Type of Expense, Amount Applied to the
Deductible and the Name of the Service Provider. See back of this form for a description of valid forms of documentation.
List each EOB separately
Date(s) of Service Description Dollar Amount
$
$
$
$
$
$
$
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2.
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Claim Total:
National Roofers Union & Employers
Joint Health & Welfare Fund
Health Reimbursement Arrangement (HRA) Claim Form
