RetiRee Medical SavingS account Premium expense ...

1 For Information or Answers to YourQuestions: (866) 278-0771 Fax or Mail Completed form To: UnitedHealthcare Service Center Box 740378 Atlanta, GA 30374 Fax: (248) 733-6144 RetiRee Medical SavingS account Premium expense reimbursement Request FormTo ensure the timely reimbursement of your eligible premiums, follow these steps to complete and submit this form : STEP 1: Get your RetiRee ID number. This is your Prudential Active Employee ID number. If you don t know it, call thePrudential Benefits Center at 1-800-PRU-EASY (1-800-778-3279) and follow the prompts for Health and Welfare Service Representatives are available to assist you from 8 to 6 , Eastern time, Monday to Fridayexcept holidays. For the hearing-impaired, please contact your local relay service. Keep a record of this number withyour other important personal information for future use. Claims cannot be processed without this 2: Gather your Premium receipts and evidence of payment for each eligible expense .

2 Itemized receipts must indicate: n Date Premium applies to n The amount of Premium paid n Covered individuals n Proof of Premium payment (cancelled checks acceptable if payment not shown on statement)STEP 3: Fill out the form carefully and print legibly. Note the following: n List the Premium expenses for yourself and your dependents (if applicable) as separate line items; n List the Premium expenses by type of coverage (for example, Prudential Medical & Prescription Drug coverage versus Medicare Part B coverage) as separate line items; and n Indicate the amount of the total Premium you paid and how much (all or a part) that you want to have 4: Read the Certification for reimbursement statement, sign and date the 5: Attach receipts and/or other documentation. n Use the original copies on white paper. Carbon copies and colored paper are not legible when scanned n Please note: If your receipt has two sides, UHC must receive all information in order to review and reimburse your claim.

3 N Tape small receipts to a standard 8-1/2 x 11 sheet of blank paperSTEP 6: Mail or fax the form with receipts and/or other documentation to the UnitedHealthcare Service Center. The mailing address and fax number are listed at the top of this page and the attached claim 7: Keep this claim form and the accompanying receipts and/or documentation (or a copy, if you mail theoriginals) with your other important papers for future TIPSn Eligible expenses : Use the RMSA to reimburse yourself for health care premiums (that is, the cost for your health coverage). Claims for out-of-pocket health care expenses (copays, coinsurance or deductibles) are not reimbursed from your Proper submission of receipts and documentation: DO NOT submit cancelled checks or credit card receipts alone. They are not adequate proof of Premium expenses without supporting documentation and an accompanying claim form . DO NOT highlight names, prices or dates on receipts.

4 Highlighted text is not legible when scanned. DO NOT handwrite information on receipts. Handwriting may cause processing Change of address: Report a change of address to the Prudential Benefits Center by calling 1-800-PRU-EASY (1-800-778-3279) and following the prompts for Health and Welfare benefits. Customer Service Representatives are available to assist you from 8 to 6 , Eastern time, Monday to Friday except holidays. For the hearing-impaired, please contact your local relay Additional claim forms: Available from UnitedHealthcare on their web site, or by phone at 1-866-278-0771. Please feel free to make copies of blank forms for future Quickest Response, complete ONLINE at: 3: CERTIFICATION FOR reimbursement I certify that the expenses submitted for reimbursement from my RetiRee Medical SavingS account (RMSA) were incurred by me (and/or my eligible dependents), have been paid by me (or them), were not reimbursed by any other program, plan, party, or account (such as a health SavingS account ), and, to the best of my knowledge and belief, are accurate, complete and eligible for reimbursement under my RMSA.

5 I (or We) will not use expenses reimbursed through this account as deductions or credits when filing my/our tax DEPENDENT SIGNATURE: _____DATE: _____ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY, FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE GUILTY OF A CRIMINAL ACT PUNISH ABLE UNDER LAW AND MAY BE SUBJECT TO CIVIL 1: RetiRee * INFORMATION (Please Print) RetiRee NAME (Last and First) RetiRee ID** RetiRee DATE OF BIRTHTELEPHONE NO. MAILING ADDRESSGROUP NO. 711612 EMPLOYER NAMEP rudential PART 2: Premium expense INFORMATION List Premium expenses for yourself and your dependents separately and provide each participant s date of OF reimbursement Check the appropriate box for each reimbursementrequested. Submit only one type of Premium per (S) OF COVERAGE MM/DD/YYYYTOTAL Premium PAIDREQUESTED REIMBURSE-MENT AMOUNTNAME:DATE OF BIRTH:Prudential RetiRee Coverage Medical & Prescription Drugs Medicare Advantage Dental VisionPrudential COBRA Medical & Prescription Drugs Dental VisionMedicare Programs Part B Part DIndependently Purchased Medical only Medical & Prescription Drugs Medicare Advantage Prescription Drugs only Dental VisionNAME:DATE OF BIRTH:Prudential RetiRee Coverage Medical & Prescription Drugs Medicare Advantage Dental VisionPrudential COBRA Medical & Prescription Drugs Dental VisionMedicare Programs Part B Part DIndependently Purchased Medical only Medical & Prescription Drugs Medicare Advantage Prescription Drugs only Dental VisionREIMBURSEMENT REQUEST TOTAL $FROM TOFROMTO* The term RetiRee also includes survivors who now manage the account .

6 ** RetiRee ID is the Prudential Active Employee ID number for the RetiRee . Call 1-800-778-3279 if you do not have : Complete this form and submit it with every request for Information or Answers to YourQuestions: (866) 278-0771 Fax or Mail Completed form To: UnitedHealthcare Service Center Box 740378 Atlanta, GA 30374 Fax: (248) 733-6144 For Quickest Response, complete ONLINE at.