IntegraFlex Online Claim Form

Boise Co-Op Claim Form

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Employee Full Name

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CERTIFICATION AND AUTHORIZATION:

The undersigned participant in the Plan certifies that all services for which reimbursement or payment is claimed by submission of this form were incurred during a period while the undersigned was covered under the Employer’s Benefit Program with respect to such expenses and that all expenses for which reimbursement is claimed by submission of this form were incurred within the Benefit Plan Year  and that the expenses have not been reimbursed and that the participant will not seek reimbursement from any other plan for these services. The undersigned understands that he or she alone is fully responsible for the sufficiency, accuracy, and veracity of all information relating to this claim which is provided by the undersigned, and that unless an expense for which payment or reimbursement is claimed is a proper expense under this Program, the undersigned may be liable for payment of all related taxes including federal, state, or local income tax on amounts paid from the Program which relate to such expense.
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