Service Forms

Use this form to establish a new Healthcare Reimbursement Account. Provide your employer a copy of this form.

Use this form to authorize Security Benefit Corporation, or its subsidiaries (“Security Benefit”), to initiate periodic electronic transactions to/from the Employer’s bank account as indicated on this form, to reflect the Employer’s Plan contribut

Use this form for each employee group adopting the Security Benefit Group Healthcare Reimbursement Account (HRA).

Use this form to transfer funds from your current carrier to Security Benefit. Complete the entire form.

Use this form to transfer funds from your current carrier to Security Benefit.

Use this form for transferring assets from your Current Carrier to Security Benefit. Please refer to the most recent 

For transferring assets from your Current Account to your NEA Valuebuilder^® Mutual Fund TSA.

Must be accompanied by the Fund Investment Options Sheet.

Use this form to transfer funds from your current carrier to Security Benefit. 

Use this form to transfer funds from your current carrier to Security Benefit.

Use this form to transfer funds from your current carrier to Security Benefit