- 13 -
Premium (from Section 2) [14]576.00
3 Spouse’s Long Term Care Insurance
Premium (from Section 2) [15]584.00
* * * * * * *
7 Medical expenses from 2001 plan year
(from Sections 3 and 4) [16]3409.00
* * * * * * *
8 Medical expenses from 2000 plan year
(from Section 5) [17]1837.00
* * * * * * *
READ, SIGN AND DATE
To the best of my [Ms. Frahm’s] knowledge and belief, my
statements in this transmittal are complete and true. I am
claiming only eligible expenses incurred during the applicable
plan year(s) and for eligible plan participants. I certify that
any part or all of these expenses have not been reimbursed
previously under this or any other benefit plan and have not been
14The amount shown is the amount, rounded to the nearest
dollar, of the premiums (i.e., $575.96) shown under the heading
“Long Term Care Insurance” for the “Employee” in “Section 2.
Insurance Benefits” quoted below.
15The amount shown is the amount, rounded to the nearest
dollar, of the premiums (i.e., $583.60) shown under the heading
“Long Term Care Insurance” for the “Spouse” in “Section 2.
Insurance Benefits” quoted below.
16We have not attempted to determine whether the “Medical
expenses from 2001 plan year” of $3,409 shown under “BENEFIT
TOTALS” in Ms. Frahm’s 2001 employee benefit form, which con-
sisted solely of noninsurance medical expenses, is the correct
total of all of the noninsurance medical expenses listed in
“Section 3 Medical Expenses” and “Section 4 Medical Expenses” of
that form. That is because those expenses are not at issue in
this case. See supra note 12.
17We have not attempted to determine whether the “Medical
expenses from 2000 plan year” of $1,837 shown under “BENEFIT
TOTALS” in Ms. Frahm’s 2001 employee benefit form, which con-
sisted solely of noninsurance medical expenses, is the correct
total of all of the noninsurance medical expenses listed in
“Section 5 Medical Expenses” of that form. That is because those
expenses are not at issue in this case. See supra note 5.
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Last modified: March 27, 2008