2012 Co-op Advertising
Blue Partner Elite General Managing Agency:
Reimbursement Form Agent Phone:
2012 Co-op Advertising allowance:
Duplicate and use this form to submit tear sheets and respective invoices
Highlight corresponding charges on the invoice(s)
Does your ad… Did you know that signs are reimbursable
…reflect the approved Blue Cross logo? through the co-op program?
…contain the 2 required taglines?
NOTE: All invoices for 2012 must be submitted by January 15, 2013
to be eligible for 2012 Program reimbursement.
Invoice(s) submitted Required Required Office Use Only
Newspaper Yellow Pages Radio Miscellaneous Invoice Expected Amount Paid Amount
Totals Reimbursement Remaining
(List $ Amt.) (List $ Amt.) YTD
If you have any questions, do not hesitate to contact Jennifer Waldemar, Co-op Advertising Coordinator, at:
651.662.8528, or toll free 1.888.878.0139, extension 28528, or email: firstname.lastname@example.org
Mail this form to: P. O. Box 64560, Rte: N184, St. Paul, MN 55164-0560