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Annual Benefit Reporting Form

For the year ended December 31, 2017.

Instructions

List Anything of Value you have received, as defined in Chapter 2.222 of the Metropolitan Code of Laws, during the previous calendar year.

Benefit type may be described by reference to the following abbreviations:

  • M =Meals, food, and beverage items
  • A = Admissions, tickets to events, or other access (including parking)
  • T = Travel expense
  • O = Other (describe)

For purposes of this report, the Member is not required to list those items set forth in Section 2.222.030 C 1and 2.


Annual Benefit Reporting Form




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