SUPPLY REQUISITION FORM McDONALD'S LICENSEES HEALTH WELFARE PLAN by KevenMealamu

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									                SUPPLY REQUISITION FORM
      McDONALD’S LICENSEES HEALTH & WELFARE PLAN
    RONALD McDONALD CHARITIES HEALTH & WELFARE PLAN

Licensee / Charity Name: ______________________________________________

Company Number: ___________________________________________________


QUANTITY                                         DESCRIPTION
(Print amount clearly)
                         Enrollment/Change Form

                         Termination Form

                         Evidence of Insurability – Life Plans

                         Evidence of Insurability – Disability Plans

                         Supply Requisition Form

                         Certificate – Licensees/Charities

                         Summary Plan Description -Licensees/Charities

                         Administration Manual

Return to:                                           Please provide your physical address:
Mercer Administration                                ________________________________
PO Box 4548                                          ________________________________
Iowa City, IA 52244-4548                             ________________________________
Fax: 1-319-887-4114
Email: McDonalds.Serviceteam@mercer.com

You can also download the above forms at www.mcdlicenseebenefits.com Just click on
“Important Forms.”

Please remember to write your company number at the top of form.


Revised 07/2009

								
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