Common Contracts
1 similar Reimbursement Agreement contracts
REIMBURSEMENT AGREEMENT DISABILITY INCOME PLANReimbursement Agreement • August 8th, 2017
Name: Social Security Number: Date of Birth: Address - Street: City: State: Zip Code: Home Telephone Number: Employee's Home E-mail Address (if available): I am familiar with and understand the provisions of my employer’s disability benefits plan(s) (the "Plan") that require that monthly payments to me will be reduced by certain amounts, such as Social Security and Workers' Compensation benefits. I understand that these reductions may sometimes be based on a reasonable estimate of the amount of other benefits that will be paid to me. I agree to these reductions. I further understand and agree that I am required to repay the Plan for any overpayments that have been made to me, including, without limitation, payments that have not been offset (or offset fully) for retroactive awards of Social Security, Workers' Compensation or other relevant benefits under the terms of the Plan and that I am required to pay the Plan any amounts that I recover from a third party in connection with my dis
