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LEOFF I – CERTIFICATION CLAIM FORM – POLICE I hereby certify under penalty of perjury that this is a true and correct claim for necessary medical expenses incurred by me, and that no payment has been received by me on account thereof. I further certify that I am an active/retired member of the Kennewick Police Department; that the following claim was required by an allowable provider; I am enclosing the required explanation of benefits; and that I am eligible for reimbursement under the following plan(s): Asuris [ ] Medicare [ ] Other [ ] Date of Condtion or Illness Provider of Service Bill Charged Co-pay Amount Service Or Prescription Name TOTAL: Print Name Signature Date Board Use Only