Get the free Please note that in order to process a refund, an IRS form W-9 must accompany this r...
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Original Surcharge Amount 9. Revised Premium Amount 10. Revised Surcharge Amount 11. Refund Amount 12. Please process my HCSF refund payment to Name of Payee Address If the insured submits the same request I agree to hold harmless the HCSF Board of Governors and the Signature Date Kansas Health Care Stabilization Fund 300 S.W. 8th Avenue 2nd Floor Topeka KS 66603-3912. Reason For Refund Request e.g. overpayment cancellation or class code 7. Original Premium Amount 8. Premium surcharge were...
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