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For HO use only: HCF

Extended Health Care Claim Form

1 | Informationaboutyou– be sure to fully complete this section

•Usethisformforallmedicalexpensesandservices.Fordentalexpenses,pleaseusetheDental Claim Form.

•Pleaseprintclearlyandbesureallsectionsarecompletetoavoiddelaysinprocessingyourclaim.

•Attachtheoriginal receiptforeachexpenseclaimedandkeepphotocopiesforyourrecords.

•Signonpage2andmailyourclaimtotheaddressatthebottomofpage2.Someplansallowclaimstobesubmittedonlineatwww.sunlife.ca.

Contract number

Member ID number Your plan sponsor/employer

Preferred language of correspondence

m English m French

Your last name First name m Male

m Female

Date of birth (yyyy-mm-dd)

– –Daytime phone number

– –Your address (street number and name) Apartment or suite City Province Postal code

2| Completethissectionifyouoryourspousearecoveredunderanotherplan

Sendyourclaimstoyourownplanfirst.Whenyoureceiveyourclaimstatement,sendacopypluscopiesofyourreceiptstoyourspouse’splantoclaimanyunpaidamount.Sendyourspouse’sclaimstotheirplanfirst,thensendacopyoftheirclaimstatementandreceiptstoyourplan.Sendyourchildren’sclaimsfirsttotheplanoftheparentwhosebirthdayfallsearlierintheyear.Isyourspouseamemberofanotherbenefitplan?m Nom YesIfyes,pleaseprovidedetailsbelow.

Spouse’s last name First name Date of birth (yyyy-mm-dd)

– –Type of coverage

m Single m Family

Are you claiming any expenses that are NOT covered under your spouse’s plan? m No m Yes If yes, please specify:

If your spouse’s benefit plan is with Sun Life Financial, do you want us to process the claim through both benefit plans?

m No m Yes

Contract number Member ID number

Spouse’s signature

XDate (yyyy-mm-dd)

– –

Areyoualsoamemberofanotherbenefitplan?m Nom YesIfyes,pleaseprovidedetailsbelow.Type of coverage

m Single m Family

Are you claiming any expenses that are NOT covered under your other plan? m No m Yes If yes, please specify:

What is your employment status under your other benefits plan?

m Full-time m Part-time m Retired

If your other benefit plan is with Sun Life Financial, do you want us to process the claim through both benefit plans? m No m Yes

Contract number Member ID number

3| InformationaboutyourclaimListthenamesofallpersonsforwhomyouareclaimingexpenses.Addupallthereceiptsandinsertthetotalamountclaimed.Ensureeachreceiptclearlyindicatesthetypeofexpensebeingclaimed. Dateofbirth Full-timePersonforwhomyouaremakingtheclaim (yyyy-mm-dd) Relationshiptoyou student Disabled Amountclaimed

Last name First name – –

m Yesm No

m Yesm No $

Last name First name – –

m Yesm No

m Yesm No $

Last name First name – –

m Yesm No

m Yesm No $

Last name First name – –

m Yesm No

m Yesm No $

Totalclaimed

$

Areyouattachingreceiptsforout-of-Canadaexpenses?m Nom YesIfyes,tellusthedateofdeparturefromclaimant’shomeprovince.Ensurethecurrencyandamountareclearlymarkedoneachreceipt.We’llassessyourclaimandconverttheeligibleexpensestoCanadiandollars.

Areanyoftheexpensesyou’reclaimingtheresultofaworkinjury? mNomYesIfyes,didyousubmityourclaimtotheworkers’compensationplaninyourprovince,ifapplicable? mNomYes

Areanyoftheexpensesyou’reclaimingtheresultofamotorvehicleaccident? mNomYesIfyes,didyousubmityourclaimtotheautomobileinsuranceplaninyourprovince,ifapplicable? mNomYes

Date (yyyy-mm-dd)

– –Out-of-Canada expenses claimed

$

20593 BCMA Health Benefits Trust Fund

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For HO use only: HCF

4| AuthorizationandSignature– you must complete this section

Icertifythatallgoodsandservicesbeingclaimedhavebeenreceivedbymeand/ormyspouseordependents,ifapplicable.Icertifythattheinformationinthisformistrueandcompleteanddoesnotcontainaclaimforanyexpensepreviouslypaidforbythisoranyotherplan.

Ifthisclaimisbeingmadeonbehalfofmyspouseand/ordependents,Iamauthorizedtodiscloseinformationaboutthem,forthepurposesofunderwriting,administrationandadjudicatingclaims.Iconfirmthatmyspouseand/ordependents,ifany,alsoauthorizeSunLifeAssuranceCompanyofCanada(“SunLife”)todiscloseinformationabouttheirclaimstome,forthepurposesofassessingandpayingabenefit,ifany,andmanagingmygroupbenefitsplan.

IauthorizeSunLifeanditsreinsurerstocollect,useanddiscloseinformationaboutme,andifapplicable,myspouseand/ordependentsneededforunderwriting,administrationandadjudicatingclaimsunderthisPlantoanyotherorganizationwhohasrelevantinformationpertainingtothisclaimincludinghealthprofessionals,institutions,investigativeagenciesandinsurers.IalsounderstandthatinformationpertainingtothisclaimmaybereviewedintheeventthisPlanisaudited.

Intheeventthereissuspicionand/orevidenceoffraudand/orPlanabuseconcerningthisclaim,IacknowledgeandagreethatSunLifemayinvestigateandthatinformationaboutme,myspouseand/ordependentspertainingtothisclaimmaybeusedanddisclosedtoanyrelevantorganizationincludingregulatorybodies,governmentorganizations,medicalsuppliersandotherinsurers,andwhereapplicablemyPlanSponsor,forthepurposeofinvestigationandpreventionoffraudand/orPlanabuse.

Ifthereisanoverpayment,Iauthorizetherecoveryofthefullamountoftheoverpaymentfromanyamountpayabletomeundermybenefitplan(s),andthecollection,useanddisclosureofinformationaboutthisclaimtootherpersonsororganizations,includingcreditagenciesand,whereapplicable,myPlanSponsorforthatpurpose.

Iagreethataphotocopyorelectronicversionofthisauthorizationshallbeasvalidastheoriginal,andmayremainineffectforthecontinuedadministrationofthisPlan.

Any reference to Sun Life Assurance Company of Canada or the Plan Sponsor includes their respective agents and service providers.

Member’s signature

XDate (yyyy-mm-dd)

– –

Respecting your privacy

Yourprivacyisimportanttous.Wemayleverageourstrengthsinourworldwideoperationsandinournegotiatedrelationshipswiththird-partyproviderstohelpusservicesomeofourcustomers.Insomeinstancesouremployees,serviceproviders,agents,reinsurersandanyoftheirserviceproviders,maybelocatedinjurisdictionsoutsideCanada,andyourpersonalinformationmaybesubjecttothelawsofthoseforeignjurisdictions.

TofindoutaboutourPrivacyPolicy,visitourwebsiteatwww.sunlife.ca,ortoobtaininformationaboutourprivacypractices,sendawrittenrequestbye-mailtoprivacyofficer@sunlife.com,orbymailtoPrivacyOfficer,SunLifeFinancial,225KingSt.West,Toronto,ONM5V3C5.

Questions?Pleasevisitwww.sunlife.caorcalltoll-free1-800-361-6212Monday-Friday,8a.m.-8p.m.ET

Mailinginstructions– keep a copy of your claim form and receipts for your records

Mailyourcompletedformtotheclaimsofficenearestyou.

1- 800-361-6212www.sunlife.ca

Sun Life Assurance Company Sun Life Assurance Company of Canada of Canada

PO Box 11658 Stn CV PO Box 2010 Stn WaterlooMontreal QC H3C 6C1 Waterloo ON N2J 0A6