How to use your Vision Reimbursement Plan What is the LAZ Vision Reimbursement plan? LAZ Parking offers a vision care reimbursement plan. Vision services are reimbursed at 100% up to the following limits: Benefit Category Annual Eye Exam Reimbursement Level Up to $50 (*if non-Anthem participant) Prescription Lenses Up to $100 Frames Up to $100 Or Contact Lenses Up to $100 Employees will be reimbursed on actual out-of-pocket expenses up to the limits listed above. Receipts for vision care services should be submitted to your home office benefits department for reimbursement. Requests received more than 30 days following the plan year or 30 days after termination will not be reimbursed. Claims Process After you have incurred an eligible expense and have your receipt from the provider, you can request reimbursement by following the steps detailed below. 1. Complete the Vision Reimbursement Form (attached). 2. Attach the itemized receipt and, if necessary, any other required supporting documentation. 3. Review the Reimbursement Form to make sure all fields are complete, including signature and date. 4. Send the completed form and supporting documentation to: LAZ Parking Attn: Rachael Cipollone 15 Lewis Street, 5th Floor Hartford, CT 06103 OR fax to: (860) 524-8249 OR email: [email protected] The home office benefits department will process your request upon receipt. Privacy The attached vision reimbursement claim will remain confidential and stored in a private file. The claim in no way can reflect upon employment. * Eligible expenses are defined by your employer and are in accordance with the plan’s benefit design. LAZ Parking P: 860-522-7641 x 775 VISION REIMBURSEMENT FORM Itemized receipt must be attached for each person/date of service. EMPLOYEE INFORMATION Name Social Security Number Street Address City State Work Telephone Zip Home Telephone ELIGIBLE VISION EXPENSES Name of Person Receiving Service Services Provided Service Amount Paid Date of Service Requested Reimbursement Amt Routine Exam Frames Prescription Lenses Contact Lenses Routine Exam Frames Prescription Lenses Contact Lenses Routine Exam Frames Prescription Lenses Contact Lenses Routine Exam Frames Prescription Lenses Contact Lenses Routine Exam Frames Prescription Lenses Contact Lenses Total I understand, agree and certify to the following: I will use my reimbursement for the above vision expenses permitted under my employer’s Vision Reimbursement plan for which I and my eligible dependents enrolled. I will not claim any reimbursed expense for federal income tax deduction or credit, and will request reimbursement only after the services have been provided. I will collect and maintain sufficient documentation to substantiate my reimbursed expenses to respond to any IRS or employer inquiries that I may receive. I specifically release my employer from any liability resulting from either my participation in or any misrepresentation I make regarding my request for reimbursement. I have read and understand the information described above. Participant’s Signature: Mail Form and Supporting Documentation to: LAZ Parking Attn: Rachael Cipollone 15 Lewis Street, 5th Floor Hartford, CT 06103 OR Email: [email protected] OR Fax To: (860) 524-8249 Date: Office Use Only Date Authorized By