main content starts here

Warwick Valley Teachers Benefit Trust

HEARING AID BENEFIT CLAIM FORM

Employee Name: ____________________________________________________

Address: __________________________________________________________

Last 4 digits Social Security Number: ____________________

Unreimbursed charges for hearing aids.

Payment is limited to $200 over a two-year period within the plan years.

Be sure your bills and/or receipts are copied and attached. Do not send originals.
This completed claim form should be mailed to:

The Preferred Group
P.O. Box 15136
Albany, New York, 12212-5136

 

Date(s): ___________     Total Amount of Claim: _______________

I certify that the above information is accurate and that the charges indicated were incurred by me or my dependents. I have not received payment for the amount of this claim from any other insurer, benefit fund, IRC 125 plan or by any other means.

 

Member’s Signature: ______________________________________________________

Date: ___________