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Get UMR AD1113 2011

Ancelled checks, non-itemized receipts and balance due bills are NOT ACCEPTABLE proof of expenses If you have questions, please call: 800-826-9781, or contact us online at www.umr.com Mail completed form along with appropriate documentation to: UMR Attention: Flexible Spending Department PO Box 8022, Wausau, WI 54402-8022 You can also fax claims toll-free to: 877-390-4782 or email them to umr-fsa@umr.com B. EMPLOYEE INFORMATION EMPLOYEE MEMBER IDENTIFICATION NUMBER PLAN YEAR EXPENSE SUBMITTED .

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