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					                                                         PREMIUM OVERPAYMENT REFUND REQUEST
           SEND TO:      MICHELLE JAMES
                         DEPARTMENT OF EMPLOYEE INSURANCE
                         501 HIGH STREET, 2ND FLOOR
                         FRANKFORT, KY 40601
    SECURE FAX:          (502) 564-0715

                                                                                                                                                          TOTAL
                                                                                    COMPANY TERM OR           BILL        REFUND    EMPLOYEE EMPLOYER    AMOUNT
LAST NAME, FIRST NAME, MIDDLE INITIAL                                    SSN         NUMBER OVERPMT          PERIOD      PAYABLE TO  PORTION  PORTION   REQUESTED




TOTAL                                                                                                                                  $0.00    $0.00        $0.00

Requester Signature:
Department/ Agency:                                                                Phone:
Address:                                                                           Secure Fax:



Refunds will only be issued upon written request
Emailed Entrust encrypted Refund Request Forms will be considered signed when sent from the authorized requesters email account.
                                           PREMIUM OVERPAYMENT REFUND REQUEST (continuation page 2)
DEPARTMENT OF EMPLOYEE INSURANCE


                                                                                                                                                          TOTAL
                                                                                    COMPANY TERM OR           BILL        REFUND    EMPLOYEE EMPLOYER    AMOUNT
LAST NAME, FIRST NAME, MIDDLE INITIAL                                    SSN         NUMBER OVERPMT          PERIOD      PAYABLE TO  PORTION  PORTION   REQUESTED




SUBTOTAL
TOTAL                                                                                                                                  $0.00    $0.00        $0.00

Requester Signature:
Department/ Agency:                                                                Phone:
Address:                                                                           Secure Fax:



Refunds will only be issued upon written request
Emailed Entrust encrypted Refund Request Forms will be considered signed when sent from the authorized requesters email account.

				
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posted:3/26/2010
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