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Prime Flex 920 is a single-component polyurethane injection resin used to seal gushing leaks, including wide gaps in concrete, where the structure is not subject to movement. This hydrophobic, low viscosity polyurethane reacts with water and expands to form a closed cell, watertight, rigid foam.

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Office Use Only / Date Processed Processed by Client PrimeFlex Form 20 Health Reimbursement Arrangement Claim Form PLEASE COMPLETE THIS FORM AND FAX IT ALONG WITH COPIES OF YOUR EOB and/or RECEIPTS TO PRIMEFLEX AT 877-6FAX-HRA. Employee Signature Date // Retain the original receipts and a copy of this form for your records. For Tax Purposes Use only for expenses incurred in the same plan year for yourself or members of your family who are dependents. PrimeFlex HRA Claims 1487 Dunwoody Drive West Chester PA 19380 877. 769. 3539 primeflexhra primepay. To be completed by employee Employee Information Please print clearly PLEASE CHECK HERE IF THIS IS AN ADDRESS CHANGE Name Last First Middle Street Social Security Number City Date of Birth State Zip Code Employer Work Telephone Number E-mail Home Telephone Number PLEASE ISSUE PAYMENT DIRECTLY TO THE MEDICAL PROVIDER S OF SERVICE LISTED BELOW. I CONFIRM THAT I HAVE COMPLETED ATTACHED THE PROVIDER PAY FORM OR INCLUDED THE MEDICAL INVOICE FOR EACH PROVIDER REQUIRING DIRECT PAYMENT FROM PRIMEFLEX. Eligible Expenses To Be Reimbursed - Please list only expenses that are eligible for this plan* Attach copies of receipts and/or EOBs on a separate piece of paper supporting each expense item listed below. Description of Expense Family Member Date Incurred Total amount this claim Amount of Claim READ CAREFULLY The undersigned participant in the plan certifies that all expenses for which reimbursement or payment is claimed by submission of this form were incurred while the undersigned was covered under the Plan with respect to such expenses. IRS regards the date incurred as being when the service is rendered not when you actually pay the bill* The undersigned participant also certifies that amounts claimed are not eligible for payment under any other health care plan or program federal state or governmental program workers compensation or any other policy of health insurance. The undersigned fully understands that he or she alone is fully responsible for the sufficiency accuracy and validity of all information relating to this claim which is provided by the undersigned* The undersigned further understands that no medical expense tax deduction is permitted for amounts for which reimbursement is made. Employee Signature Date // Retain the original receipts and a copy of this form for your records. For Tax Purposes Use only for expenses incurred in the same plan year for yourself or members of your family who are dependents. PrimeFlex HRA Claims 1487 Dunwoody Drive West Chester PA 19380 877. 769. 3539 primeflexhra primepay. Eligible Expenses To Be Reimbursed - Please list only expenses that are eligible for this plan* Attach copies of receipts and/or EOBs on a separate piece of paper supporting each expense item listed below. Description of Expense Family Member Date Incurred Total amount this claim Amount of Claim READ CAREFULLY The undersigned participant in the plan certifies that all expenses for which reimbursement or payment is claimed by submission of this form were incurred while the undersigned was covered under the Plan with respect to such expenses. .

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