CHANCELLOR & CHANCELLOR, INC.
SECTION 125 PLAN
MEDICAL CARE EXPENSE CLAIM FORM


Social Security No.: ___________________________ 


Participant's Name: _________________________________________________________
                    Last                        First                   Middle

To: Chancellor & Chancellor , Inc.

The undersigned participant in the plan requests reimbursement in the amounts 
shown below: (If additional space is needed please use the attached sheet.)

NOTE: Federal law requires that you submit a written statement (such as an 
itemized bill from the benefit provider) as well as proof that the claim is 
not being reimbursed by an Insurance Company. Also, you will not be entitled 
to claim this expense as a tax deduction.



MEDICAL CARE EXPENSE
 Date       Name of Service     Describe      Person for Whom       Net         
Incurred        Provider        Expense       Expense Incurred    Amount


__________  _________________  ___________   __________________  $_________

__________  _________________  ___________   __________________  $_________

__________  _________________  ___________   __________________  $_________

Amount from attached form                                        $_________

Total amount of medical expenses                                 $_________

READ CAREFULLY

The undersigned participant in the plan certifies that all expenses for which 
reimbursement or payment is claimed by submission of this form, were incurred
during a period while the undersigned was covered under the Chancellor &

Chancellor, Inc. Section 125 Plan with respect to such expenses and that such
expenses have not been reimbursed, or are not reimburseable, under any other
health plan coverage. The undersigned fully understands that he or she alone
is fully responsible for the sufficiency, accuracy and veracity of all 
information relating to this claim which is provided by the undersigned, and 
that unless an expense for which payment or reimbursement is claimed is a 
proper expense under the Plan, the undersigned may be liable for the payment
of all related taxes including federal, state or city income tax on amounts
paid from the plan which relate to such expense. The undersigned further 
understands that no medical expense tax deduction or credit is permitted for
amounts for which reimbursement is made.

_____________________________________           Date_______________________
Employee's signature


For Plan Administrator use only                 For Employer use only

Payment Authorized ___________                  Check No.____________

Amount $______________________                  Date ________________


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or mail us the completed form.)