Qualifying Health Reimbursement Program
Name
First Name
Last Name
Email
example@example.com
Requesting Reimbursement
Single Coverage Reimb (Up to $150)
Single plus Dependent Coverage (Up to $300)
Attest to the following:
Rows
Yes
No
Did you work at least 112 hours last month?
Did you pay health insurance premiums or health sharing expenses last month?
Are you eligible for coverage from a spouse, partner or parent's plan?
Please upload copy of insurance payment
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