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Get Aflac M0272B 2010-2024

Ts attached must be clear and legible. 2. The Total Dependent Care Reimbursement requested box must be completed. 5. Allow 48 business hours to check status of reimbursement request. 3. The Medical Care Total requested box must be completed. 6. Please maintain copies of all receipts for your records. Check here if address change Employee Information Participant s Social Security Number (Optional) Last Name Employer Name First Name Street Address Middle Initial Participant's E-Mail A.

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