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Page 1 of 2EHC-E-06-10
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
$
Page 2 of 2EHC-E-06-10
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,[email protected],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