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Annual Claim Porm <br />publiic Safety, t7fficer's bisability 13euefit 299A.465 <br />Minnesota Department of Public Safety <br />tlft'icpofthe: Gstatubsioner <br />449 Minnesota Street,:Suite 10.-00 <br />St, P°u1'Mitnesota 55101 <br />Phone 651201-7163 /Fox 651297-5728 <br />For assistance in defraying a portion of employer's cost to provide health insurance benefits to <br />Peace Officers. or Fire Fighters (does not i'n'clude volunteer• fi'r.e fighters) as provided in <br />Minnesota Statute 299A.465, Continued Health Insurance Coverage. <br />Return this form to the address above no later titan <br />Late04us will not be accepted <br />CITY OF ST. ANTHONY <br />Name of agency (Employer) requesting'reimbursemetnt <br />3301 SILVER LAKE. RD ST. ANTHONY MN 55418 <br />ROGER LARSON 612-782-3316 6/25/2010 <br />`1'itte Telephone Date <br />Name afClaimaot(Last, Rush, Middle) Date of I3itlh Socitd SecuritF n ber <br />AddI —ess City State <br />o'fClaimant (if available) <br />Hniployer paid for employee's health coverage:: <br />from_7/1/200'3to 6/30/2010 * duringthis claim period <br />Number of parsons, including emplcayec who received coverage:__ <br />Was the provided coverage primary or secondary? PRIMARY , <br />During the claim period Jti1y 109 __ to June 36, 10 the cutployer paid: <br />`6 7 , 550 37 _ _ for employee insurance coverage* <br />Date <br />Zip <br />IN <br />Attach receipts and/or doeumeutation to substantiate the dollar amount and number of months <br />that employer paid for this employee. Claims without documentation will not be approved for <br />payment. _ <br />R""" -d e:2001 <br />