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Get SECTION 125 - REIMBURSEMENT CLAIM FORM - IPMG - Insurance ...

Or worksheet from your Health/Dental plan(s). NOTE: If you or a dependent are covered by two health plans, attach the Explanation of Benefits worksheet from both plans to claim the amount not paid by either plan. 2) For other items considered reimbursable by the IRS, copies of itemized receipts obtained from the provider of the services. 3) Mail your claim to: A CLAIM IPMG Employee Benefits Services 225 Smith Rd. St. Charles, IL 60174 Phone: 630-789-2082 Fax: 630-203-4580 Website Submit.

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