Non-Financial Change for Group Healthcare Reimbursement (HRA)

Other

For changing the name and/or address of the existing participant or IRS eligible dependent.

Download: Instructions

Please type or print in black ink. Complete all necessary fields and signatures.

By Mail

Security Benefit Retirement Plan Services
PO Box 219141
Kansas City, MO 64121-9141
United States

Overnight Delivery

Security Benefit Retirement Plan Services
801 Pennsylvania Ave Ste 219141
Kansas City, MO 64105-1307
United States

By Fax

816.701.7626

Download

Questions? Please call our National Service Center at 800.747.3942.