Fringe Benefit Information

Please fill out a separate form for each owner

 
  • OWNER(s) HEALTH INSURANCE PAID VIA THE PRACTICE

  • BUSINESS AUTOMOBILE QUESTIONNAIRE

  • *If the business mileage (not including commuting) is less than 50% of the total, please contact your account manager and do not return this form.
  • I have completed the above to the best of my ability. By signing below, I affirm that I have written evidence to support my information.
  • Date Format: MM slash DD slash YYYY
 
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