LAWRENCE UNIVERSITY Student Health Insurance …

2077 Roosevelt Avenue Springfield, MA 01104 877.657.5030 Toll-Free: 800.633.7867 @CHPstudent @CHP @CHP Student’s Name: _____ Last First Middle

Family Medical Leave and/or Dependent Care …

4. For all employees who request a leave due to a personal serious illness (not associated with a disability claim), a birth of a child or the need to care for a seriously ill child, spouse, parent, qualifying exigencies or illness/injury of a service member, I must complete the “Certification of Health Care Provider” form (see above for proper form) …

  Form, Medical, Care, Claim, Dependent, Or dependent care

State of Connecticut Medical Flexible Spending …

Claim Form Purpose IRS Code Publication 502 defines qualified medical care expenses as amounts paid for: (1) the diagnosis, cure, mitigation, treatment or prevention of disease or for the purpose of affecting any structure or function of the body;

  Form, Medical, Connecticut, Flexible, Care, Claim form, Claim, Spending, Of connecticut medical flexible spending, Medical care

How to File Claims IRS guidelines require specific ...

MoCafe Claim Form. NOTE: If you submit your claim, this form is not needed. Your Name (Last, First, MI) Social Security No. or EID or PIN Your Employer Name

  Form, Claim form, Claim

MAIL TO: FAX TO: Reimbursement Accounts Claim …

MAIL TO: PayFlex Systems USA, Inc. P.O. Box 3039 Omaha, NE 68103-3039 (800) 284-4885 Reimbursement Accounts Claim Form FAX TO: PayFlex Systems USA, Inc.

  Form, Claim form, Claim, Payflex

RC001 EHC Claim - RWAM Insurance

EHC CLAIM EXTENDED HEALTH CARE BENEFITS RC001_09.13 EMPLOYEE STATEMENT Employer Date of Birth (dd/mm/yy) Male Female Group # Certificate # Employee Name Employee Address (Street, City, Province and Postal Code)

  Care, Claim, Rc001 ehc claim, Rc001

PayFlex Flexible Spending Account (FSA) / Limited ...

: I certify thatI have incurred the Dependent Day Care expenses for me and, if married, my spouse to work. These expenses are for my Qualifying

  Care, Dependent