Vicar Reimbursement Request

Helpful Tips
1. Navigate through the form by using the Previous/Next buttons or by selecting one of the seven tabs.
2. A field marked with a red asterisk is required.
3. Be prepared to provide the Service Period as indicated on your utility bill(s) and/or Service Dates as indicated on your Explanation of Benefits (EOB).
4. The dollar amount fields will automatically calculate and display in the TOTAL fields.
5. If requesting medical reimbursement for more than one family member, please use a separate Patient tab (e.g., Patient 1, Patient 2, etc.) for each family member.
6. Be prepared to upload copies of your utility bill(s) and/or Explanation of Benefits (EOB) on the last page of the form.

Reimbursement Details
1. Vicar's are eligible for reimbursement of housing and utility expenses in excess of $425 per month.
2. When submitting a reimbursement request each month, please upload the following documentation:
- A copy of your rental/lease agreement when submitting your first reimbursement request.
- A copy of all monthly utility bills.
3. All reimbursements will be added to your paycheck as taxable income.
4. For details on medical reimbursements, please see the separate Medical Reimbursement Policy.

Reimbursement Schedule
This schedule is subject to change without notice depending upon how business days fall during a pay period.
- Requests received between the 23rd and the 6th of the month will be paid on the paycheck dated the 15th of the month.
- Requests received between the 7th and 22nd of the month will be paid on the paycheck dated the last day of the month.

Vicar Information
A field marked with a red asterisk is required.
Name*
First Last
E-mail*
Enter e-mail Confirm e-mail
Church name*
City*
State / Province*

Housing/Utility Reimbursements
• Include the Service Period from your billing statement.
• Select the help icon for a description of Rent Offset.
Rent from
MM slash DD slash YYYY
Rent to
MM slash DD slash YYYY
Amount
Electric from
MM slash DD slash YYYY
Electric to
MM slash DD slash YYYY
Amount
Gas/Oil from
MM slash DD slash YYYY
Gas/Oil to
MM slash DD slash YYYY
Amount
Water/Sewer from
MM slash DD slash YYYY
Water/Sewer to
MM slash DD slash YYYY
Amount
Other from
MM slash DD slash YYYY
Other to
MM slash DD slash YYYY
Amount
Please describe Other expenses*
Total rent and/or utility expenses.
?
Expense(s)
Less monthly out-of-pocket maximum of $425.
?
Less Out-of-Pocket
If requesting reimbursement of utilities ONLY and have already received your rent reimbursement for this month, enter $425 to offset the monthly out-of-pocket maximum already applied so total reimbursement calculates correctly.
?
Rent Offset
Please enter a number from 425 to 425.
Total reimbursement
?
TOTAL

Medical Reimbursements for Patient #1
Complete a separate medical reimbursement request for each family member.
Name of patient #1
First Last
Deductible Expenses
• Include the Service Dates from your Explanation of Benefits (EOB).
• Select the help icon for a description of Deductible Offset.
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Deductible amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Deductible amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Deductible amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Deductible amount(s)
Total deductible expenses.
?
Deductible expenses
Less out-of-pocket maximum of $250.
?
Less Out-of-Pocket
If you have already met your $250 out-of-pocket maximum, enter $250 to offset your out-of-pocket maximum.
?
Deductible Offset
Please enter a number from 250 to 250.
Total deductible reimbursement.
?
TOTAL
Coinsurance Expenses
• Include the Service Dates from your Explanation of Benefits (EOB).
• Select the help icon for a description of Coinsurance Offset.
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Coinsurance amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Coinsurance amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Coinsurance amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Coinsurance amount(s)
Total coinsurance expenses.
?
Coinsurance expenses
Less out-of-pocket maximum of $1,333.
?
Less Out-of-Pocket
If you have already met your $1,333 out-of-pocket maximum, enter $1,333 to offset your out-of-pocket maximum.
?
Coinsurance Offset
Please enter a number from 1333 to 1333.
Total coinsurance reimbursement.
?
TOTAL

Medical Reimbursements for Patient #2
Complete a separate medical reimbursement request for each family member.
Name of patient #2
First Last
Deductible Expenses
• Include the Service Dates from your Explanation of Benefits (EOB).
• Select the help icon for a description of Deductible Offset.
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Deductible amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Deductible amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Deductible amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Deductible amount(s)
Total deductible expenses.
?
Deductible expenses
Less out-of-pocket maximum of $250.
?
Less Out-of-Pocket
If you have already met your $250 out-of-pocket maximum, enter $250 to offset your out-of-pocket maximum.
?
Deductible Offset
Please enter a number from 250 to 250.
Total deductible reimbursement.
?
TOTAL
Coinsurance Expenses
• Include the Service Dates from your Explanation of Benefits (EOB).
• Select the help icon for a description of Coinsurance Offset.
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Coinsurance amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Coinsurance amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Coinsurance amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Coinsurance amount(s)
Total coinsurance expenses.
?
Coinsurance expenses
Less out-of-pocket maximum of $1,333.
?
Less Out-of-Pocket
If you have already met your $1,333 out-of-pocket maximum, enter $1,333 to offset your out-of-pocket maximum.
?
Coinsurance Offset
Please enter a number from 1333 to 1333.
Total coinsurance reimbursement.
?
TOTAL

Medical Reimbursements for Patient #3
Complete a separate medical reimbursement request for each family member.
Name of patient #3
First Last
Deductible Expenses
• Include the Service Dates from your Explanation of Benefits (EOB).
• Select the help icon for a description of Deductible Offset.
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Deductible amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Deductible amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Deductible amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Deductible amount(s)
Total deductible expenses.
?
Deductible expenses
Less out-of-pocket maximum of $250.
?
Less Out-of-Pocket
If you have already met your $250 out-of-pocket maximum, enter $250 to offset your out-of-pocket maximum.
?
Deductible Offset
Please enter a number from 250 to 250.
Total deductible reimbursement.
?
TOTAL
Coinsurance Expenses
• Include the Service Dates from your Explanation of Benefits (EOB).
• Select the help icon for a description of Coinsurance Offset.
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Coinsurance amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Coinsurance amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Coinsurance amount(s)
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Coinsurance amount(s)
Total coinsurance expenses.
?
Coinsurance expenses
Less out-of-pocket maximum of $1,333.
?
Less Out-of-Pocket
If you have already met your $1,333 out-of-pocket maximum, enter $1,333 to offset your out-of-pocket maximum.
?
Coinsurance Offset
Please enter a number from 1333 to 1333.
Total coinsurance reimbursement.
?
TOTAL

Upload Documents
Upload copies of your utility bill(s) and/or Explanation of Benefits (EOB).
• File extensions allowed: pdf, doc, docx, jpg, xls, xlsx, zip
• Maximum file size allowed: 4MB
Drop files here or

Accepted file types: pdf, doc, docx, jpg, xls, xlsx, zip, Max. file size: 4 MB.
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Vicar Information

Housing/Utility Reimbursements

Medical Reimbursements for Patient #1

Deductible Expenses

Coinsurance Expenses

Medical Reimbursements for Patient #2

Deductible Expenses

Coinsurance Expenses

Medical Reimbursements for Patient #3

Deductible Expenses

Coinsurance Expenses

Upload Documents

Signature