ICC Chapter Education Benefit Reimbursement Form

ICC Chapter Education Benefit Reimbursement Form
For Preferred Provider (PP) Training reimbursement in compliance with the Chapter Education Benefit Policy for completing part one of the annual report. The maximum reimbursement is $1200.
Chapter Name:*
Chapter Number:*
Log into your MyICC account or check previously received emails if you do not have this number saved.
Your Name:*

First NameLast Name
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Make Check Payable to:
List the individual or the Organization the check should be made payable to.
Mailing Address (where check should be mailed):*

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Provider Name, if applicable
Preferred Provider Number
Reimbursement Request Amount*
Amount should not exceed $1200
Date of Training

MonthDayYear
Date
Expense Description
Please attach your training invoices and receipts here. *

Cancelof
Should be Empty: