Fidelity Retiree Health Plan Reimbursement Request Form

1 EMAIL ADDRESSPARTICIPANT LAST NAME PHONE # (AREA CODE FIRST NO DASHES) --SSNDate of service [mm/dd/yyyy] Provider name Type of service Total expense amount Amount paid by insurance Amount paid by you Start date End date Requested amount TOTAL Reimbursement Request EMPLOYEE INFORMATION [Your Email address currently on file will be used. If you ve had a change of address, please update your information on Fidelity NetBenefits ] ITEM(S) FOR Reimbursement If you are filing a claim for your spouse, please fill out the following information: Patient's name Relationship to participant Patient s date of birth [mm/dd/yyyy] I certify that to the best of my knowledge the above information is accurate and that the Reimbursement is being requested only for expenses incurred by me and/or my spouse. I am requesting Reimbursement only for eligible medical expenses as defined in IRS Publication 502 or 969. I authorize Acclaris, as the administrator for FMR LLC, to reimburse me for the amount requested from my Retiree Health Reimbursement Plan.

2 I understand that any person who knowingly and with intent to defraud or deceive any claims Reimbursement company, who files a statement of claim containing any materially false or misleading information, is guilty of a crime and may be liable for substantial civil penalties, and I will hold Acclaris harmless for payment of any ineligible expenses presented in such a manner. Employee Signature:_____ Date:_____/_ _____/_ _____ PLEASE KEEP A COPY FOR YOUR RECORDS Fidelity Retiree Health Plan Reimbursement Request Form PARTICIPANT FIRST NAME The Fidelity Retiree Health Reimbursement Plan [RHRP] is designed to reimburse eligible participants for eligible medical expenses incurred on retirement. Once an employee becomes eligible to get a Reimbursement under this plan, they can submit their Request under this plan. Terminated from Fidelity employment with at least 10 years of service and is at the age of 55 or older The ex-spouse of a Plan participant who has continued Plan coverage under COBRA The surviving spouse of an eligible employee with Plan creditslantails Maximum Reimbursement : Up to the funds available in your Disbursement Eligible RHRP account.

3 Submission Cut-off: 24 months from the date of expense incurred. Plan credits The Plan allows Fidelity to give annual Retiree Health Reimbursement Plan credits to each eligible employee. Fidelity intends to give the following credits: $3,000 credit for regular employees scheduled to work 30 or more hours per week $1,500 credit for regular employees scheduled to work at least 20 hours but less than 30 hours per week The annual credit is determined each year, subject to the availability of sufficient company profits and cash flow In addition, employees must meet initial and ongoing eligibility requirements Eligible employees who die or retire during the year receive a pro-rated credit based on the number of monthsworked during the year in which the employee died or retired Medical expense as defined within IRS Code section 213[d] and as allowed under Code section 105 are reimbursed Long Term Care Premiums are eligible reimbursements and is subject to the IRS age rated limitations amounts Deductibles Copayments Out-of-pocket medical expenses not covered, or partially covered, by medical, dental, or other group Health plans Medical plan premiums, including COBRA premiums Medicare premiums, including Part A, Part B, Part D and Medicare HMOs for individuals over age 65(Note: For a complete list of qualified eligible expenses, go to and refer to IRS publications 502 or 969)Eligibility Program description Eligible expenses examples Submission Cut-off Example: Expenses incurred on 05/01/2015 should be submitted for Reimbursement by 05/01/2017 Plan credits1 | P a gePlan detailsFidelity Retiree Health Plan Reimbursement Request Form Eligible expenses A completed Reimbursement Request form with participant signature Supporting documents as mentioned below.

4 OFor medical expense Reimbursement [Either of the following]: Explanation of Benefits [EOB] or account activity from insurance carrier Receipts provided by the providers with description of service, service dates, patient name andpayment amountoFor drug/medicine Reimbursement [Either of the following]: Payment receipt with RX number Customer statement report from the drug provider containing the RX number and patientpaid/responsibility amount Medicine co-payment receipts Benefit summary or explanation of benefit from insurance carrieroFor insurance premiums [Either of the following]: Account summary from the insurance carrier Bank account statement of the participant for the monthly ongoing insurance premium Employee payslip from where we can determine monthly insurance premium deduction of theparticipantoLong term care insurance premiums: Insurance statement from the provider with the name of the insured person along with the coverageperiod NetBenefits Payment Details for COBRA coverage Required documents Valid documents must include the following information: Name of provider Who the expense is for Date of expense Description of expense Dollar amount2 | P a ge Submit online or check the status of your submission online at: Keep this original form for your records.

5 Make a copy of this form and submit it to:Fax: 1- 813-830-7900 Or Mail To: Acclaris, Box 25171, lehigh valley , PA 18002-5171 Su bmission of Reimbursement requests Fidelity Retiree Health Plan Reimbursement Request Form