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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...
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