Auburn, WA · King County
LEOFF 1 Claim for Payment Form
This form lets LEOFF 1 retirees submit medical, prescription, dental, or vision bills to the City of Auburn for payment consideration.
What this form is
LEOFF 1 retirees use this form to claim payment for medical, prescription, dental, or vision services. It asks for claimant and bill details, insurance information, and a certification and signature; the form also has a section for the LEOFF Board’s approval or denial. Include all required backup documentation, and indicate whether an insurance explanation of benefits and payment receipt are attached.
Who needs it
A LEOFF 1 retiree seeking payment consideration for medical, prescription, dental, or vision bills submits this claim form.
How to submit it
Send claims to City of Auburn HR Dept., Attn: LEOFF Board Secretary, 25 W Main St, Auburn, WA 98001. Include all required backup documentation with the claim form.
About notarization
This document is signed and dated by the claimant without a notary; the form does not identify any notarized or sworn attachment or related step.
How to submit this form
- 1
Download The Form
Download the LEOFF 1 Claim for Payment Form PDF.
- 2
Complete The Claim
Enter claimant, bill, service-date, and insurance details, then sign and date the certification.
- 3
Gather Supporting Documents
Include all required backup documentation and indicate whether an insurance explanation of benefits and payment receipt are attached.
- 4
Send The Claim
Mail the claim to the City of Auburn HR Dept., Attn: LEOFF Board Secretary, 25 W Main St, Auburn, WA 98001.
Frequently asked questions
- Who uses the LEOFF 1 Claim for Payment Form?
- LEOFF 1 retirees use it to submit claims for medical, prescription, dental, or vision bills to the City of Auburn.
- What documents should I include with my claim?
- The form says all required backup documentation must be included. It asks whether an insurance explanation of benefits and a payment receipt are attached.
- How do I submit the LEOFF 1 claim form?
- Send the completed form and required backup documentation to City of Auburn HR Dept., Attn: LEOFF Board Secretary, 25 W Main St, Auburn, WA 98001.
- Do I need a notary for the LEOFF 1 Claim for Payment Form?
- No. The claimant signs and dates the form; it does not identify any notarized or sworn attachment or related step.
Need something notarized?
This LEOFF 1 Claim for Payment Form doesn’t need a notary — but if you have another Auburn form that does, a commissioned online notary can help.