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Get Wellmark BCBS H-8772 2010-2024

Zip Employer Name Effective Date / Location/Class Date of Birth / / / Employee Reimbursement Account Agreement I agree to have my gross salary redirected, in accordance with Section 125 of the Internal Revenue Code, to contribute in the amounts indicated below. I understand that contributions to my reimbursement account(s) can only be reimbursed to me for eligible expenses incurred within each plan year. For example, funds in the Medical Reimbursement Account cannot be used for rei.

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