Dental Reimbursement
You need to submit an itemized receipt, showing amount you paid.
Name: _______________________________________________________________
Address: _____________________________________________________________
City: _____________________________ State: ________ Zip: ______________
SSN: __________________________________
Write "Colorado Pipe Dental Benefits" on receipt
Please Enclose copy of dental bill & copy of receipt showing payment
Mail to: Colorado Pipe Dental Benefits
C/O Fringe Benefit Services, Inc.
P.O. Box 21240
Denver, CO 80221-0240
Please note: Dental benefits have changed. As of January 1, 2011 you will receive 90% reembursement for one exam, cleaning and x-ray per person per year instead of the $400.00 reembursement.
The fund office will need an itemized statement from your dentist stating that you have paid. Please submit that along with this form.