EUTF Claim Form
Current Plan Year: July 1, 2022 to June 30, 2023
UPDATE: To ensure proper posting, please use one claim form per person per plan year.
Please Note: The filing deadline for dates of service between July 1, 2021 and June 30, 2022 is 180 days (December 27, 2022) after the plan year ends or 180 days after your termination date, whichever is earlier. The plan will not pay any claims received after the filing deadline.
Please follow the Claim Filing Requirements. Complete the information below for medical care and/or prescription drug expenses that were incurred by you or your eligible dependents. The services must have been paid by your primary health insurance plan to be eligible for reimbursement. Failure to complete the required information on this form or follow the Claim Filing Requirements will result in a delay in processing your claim.