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Flexible Benefit Plan Reimbursement Request
Dependent Day Care Provider Acknowledgement
Letter of Medical Necessity
Private Health Information (PHI) Release Form
Transportation Plan Reimbursement
Flexible Benefits Card Substantiation Coversheet
Orthodontia Treatment Statement
Medical Care Worksheet
Dependent Care Worksheet
Hospital and Other Insurance Premium Reimbursement Request
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COBRA Triggering Events
Triggering Events Listed in the Statute
Death of the covered employee
Voluntary or involuntary termination of the covered employee's employment (other than by reason of gross misconduct), or reduction of hours of the covered employee's employment
Divorce or legal separation of the covered employee from the employee's spouse
Covered employee becomes entitled to benefits under Medicare
Dependent child ceasing to be a dependent child under the generally applicable requirements of the plan
An employer's bankruptcy (but only with respect to health coverage for retirees and their families)
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