WISCONSIN ELECTRICAL
EMPLOYEES BENEFIT FUNDS

2730 DAIRY DRIVE * SUITE 101 * MADISON, WI 53718 * PHONE (608) 276-9111 * WATS 1 (800) 422-2128
RECEIVING FAX (608) 276-9103 * HEALTH CLAIM FAX (608) 288-9095
SPONSORED BY: INTERNATIONAL BROTHERHOOD OF ELECTRICAL WORKERS
LOCAL UNION # 14, 127, 158, 388, 430, 577, 890
NATIONAL ELECTRICAL CONTRACTORS ASSOCIATION-WISCONSIN CHAPTER

DATE	PATIENT	PROVIDER	TYPE OF SERVICE	AMOUNT




To the best of my knowledge and belief, my statements in this Form are complete and true. I certify all of the following: Either I have or a dependent has received the services described above on the dates indicated, and the expenses are my out-of-pocket expenses that qualify as valid Medical Expenses under the Plan. If the expense is for my Spouse or Dependent, the person listed is my spouse or dependent as defined under the Plan. I have not been reimbursed previously for these expenses under the Flexible Benefit Arrangement. These expenses have not been reimbursed or are not reimbursable under any other source available for reimbursement (i.e, the Fund's health plan or any other health plan, such as my spouse's plan). I understand that the expenses reimbursed may not be used to claim any federal income tax deduction or credit. I authorize a deduction in my Flexible Benefit Account in the amount of the reimbursement. Employee Signature: _______________________________ Date___________________________ MR PETER A. RISBERG WISCONSIN ELECTRICAL EMPLOYEES HEALTH & WELFARE FUND 2730 DAIRY DRIVE SUITE 101 MADISON, WI 53718 TOTAL

Employee Name: ________________________________________________________________
Social Security No. ______________________________________________________________
Address:_______________________________________________________________________

Instructions:
Complete the information below for Medical Expenses incurred by you, your spouse or other eligible dependants. (For information as to what Medical Expenses can be reimbursed, see the Summary Plan Description.) You must provide your insurance Explanation of Benefit Forms (EOB's) along with hospital or doctor bills, receipts, or other evidence that the Medical Expenses were incurred. Be sure to provide all information requested by this Form. If the Form is incomplete, it will be returned to you. Please date and sign the Form, then send it along with you supporting documentation to the Claims Administrator at the address below.

FLEXIBLE BENEFIT REIMBURSEMENT ARRANGEMENT
REQUEST FORM