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(Last, First, MI) NDPERS ID Number Your Employer Name NDPERS Retiree Health Insurance Credit Program Address City State Zip Code Insurance Premium Claims (other than Medicare) Please include appropriate documentation as required by your employer plan with this completed claim form as follows: Itemized statement from the insurance company showing the dates for which premium is being paid, the type of insurance, the dollar amount of the premium; and, Proof of payment in the form of.

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