Health Reimbursement Arrangements (HRA) Forms

Participant Forms

• HRA Q & A (Employee Version)
• Partial Listing of 213(d) Eligible Medical Expenses
• Premium Only Listing of Eligible Expenses
• Health Reimbursement Arrangement Non-Recurring Claim Form
  Expenses must be incurred prior to submitting a request for reimbursement. Approved HRA claims are processed within 7 – 14 business days.
• Health Reimbursement Arrangement Recurring Claim Form
  Per IRS regulations, you must provide monthly documentation showing that your expenses were incurred.
• Health Reimbursement Authorization for Direct Deposit Form
  Once your claim has been processed, it may take up to 72 hours for the funds to post to your designated bank account.
• AUL Investment Change and Transfer Form
  This form may be used only if your funds are invested in AUL’s variable product and your Plan allows for diversification of funds.