	EFLEXGROUP.COM, INC. Fax 608.245.9342 National Fax 877.231.1287
Adjudication for eflex convenience card

Employee Name: Social Security Number:

Employer Name:

Please Attach Receipts Below and
Fax to eflexgroup

Employee Name:	Social Security Number:
Employer Name:
Please Attach Receipts Below and Fax to eflexgroup