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121 Benefits730 2nd Ave. S., Ste. 400
730 Building
Minneapolis, MN 55402
Phone: 800.300.1672
Fax: 877.918.3622
www.121benefits.comFlexible Benefits Enrollment Form
Benefit Year
Last Name
Address
Employer
Date
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Information such as the name of the authorizer, the details of the authorization, and any relevant dates must be reported on i authorize form following.
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