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Acclaris Center Form
Calendar year in which you incur a reimbursable expense. Reimbursement services provided by Acclaris Send completed forms to: Acclaris Reimbursement Center PO Box 25171 Lehigh Valley, PA 18002-5171 Fax completed forms to: 1-813-830-7900 Inquiries: Online: 1-888-880-2775, 1-877-314-2240(TTY) www.acclarisonline.com Part I: General Information (Please Print) Retiree/Surviving Spouse Name (Last, First MI) Social Security Number IBM Serial Number Other Coverage: If any of the charges...Show details
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