Fillable Cost Plus Claim Form WHEN IS COST PLUS (RBC Insurance)

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Cost Plus Claim Form WHEN IS COST PLUS (RBC Insurance)

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Country of origin: CANADA
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VPS 105212 103259 (07/2019)
Page 1 of 3
WHEN IS COST PLUS USED?
Cost Plus is used to reimburse health or dental expenses not fully covered under the Extended Health or Dental Care plan.
To be considered for reimbursement, the expense must be eligible under the Income Tax Act (Canada).
Canada Revenue Agency (CRA) may determine that Cost Plus benet coverage does not qualify as a Private Health Services Plan,
and therefore any Cost Plus claim processed on this basis may not qualify as a valid business expense or as non-taxable income to the
plan member. Canada Revenue Agency (CRA) has indicated that a personal Cost Plus plan for the owner/proprietor (and dependents)
only may not qualify as a Private Health Services Plan.
To determine if Cost Plus benet coverage is the right solution for your business, please seek the appropriate tax advice.
TO SUBMIT A COST PLUS CLAIM, WE REQUIRE THE FOLLOWING
A fully completed Cost Plus Claim Form, signed by the Plan Administrator.
The original itemized receipt for each expense claimed. Cash register tapes and credit card receipts are not accepted.
If the claim has been partially paid by a group benets program, please attach the Explanation of Benets (EOB) from
the insurance company. Original receipts are not required when the EOB is included.
Payment to RBC Insurance
®
in the amount of the total expenses being claimed, plus our administration fee, plus applicable taxes.
Payment can be made as follows:
By cheque; or
By pre-authorized debit; if your plan has this service in place, Cost Plus will show on your billing statement.
Notes
Administration fee: 10% of total claimed amount, subject to a minimum charge of $25 per claim and a maximum
of $300 per claim;
The minimum claim amount eligible for reimbursement is $100. Receipts must be accumulated to an amount of $100
or more per plan member before submission.
CALCULATION EXAMPLE (ONTARIO CLAIM)
Total Health Claims $ 250.00 A
Total Dental Claims $ 250.00 B
Total Amount Claimed (A + B) $ 500.00 C
C * 10% Administration Fee (minimum $25, maximum $300) $ 50.00 D
Sub-total (C + D) $ 550.00 E
E * Premium Tax (ON/QC/NL only) % $ 11.00 F
D * GST/HST (on admin fee only) % $ 6.50 G
C * PST (on total ON/QC claims only) % $ 40.00 H
Total amount due to RBC Insurance (E + F + G + H) $ 607.50
Cost Plus Claim Form
VPS 105212 103259 (07/2019)
Page 2 of 3
Administrative Details
Name of Employer RBCI Policy No. Billing Division No.
Address (Street, City, Postal Code) Province
Plan Member Name (Last, First) Plan Member ID No.
Plan Member Address (Street, City, Province, Postal Code)
Claim Amount – Calculation
Total Health Claims $ A
Total Dental Claims $ B
Total Amount Claimed (A + B) $ C
C * 10% Administration Fee (minimum $25, maximum $300) $ D
Sub-total (C + D) $ E
E * Premium Tax (ON/QC/NL only) % $ F
D * GST/HST (on admin fee only) % $ G
C * PST (on total ON/QC claims only) % $ H
Total amount due to RBC Insurance (E + F + G + H) $
Premium Tax PST GST HST
ON 2% ON 8% AB 5% ON 13%
QC 3.48% QC 9% MB 5% PEI 15%
NL 4% SK 5% NS 15%
BC 5% NB 13%
YK 5% NL 13%
NT 5% QC 14.975%
NU 5%
0.00
0.00
0.00
0.00
0.00
0.00
0.00
VPS 105212 103259 (07/2019)
Page 3 of 3
Notes to Plan Administrator
Send Cost Plus package to RBC Insurance, P.O. Box 1600, Windsor, ON, N9A 0B3, Attention: Client Administration.
Expenses claimed must be considered eligible medical expenses according to Canada Revenue Agency Income Tax Folio
S1-F1-C1: Medical Expenses Tax Credit.
Visit the CRA website at www.cra.gc.ca to view the complete list of eligible medical expenses (from S1-F1-C1). CRA’s toll-free
number is 1-800-959-8281.
Eligible dependents, for the purposes of the medical expense tax credit, are dependents who qualify as a “dependent” for that
particular taxation year according to CRA.
Keep a photocopy for your records.
Incomplete or incorrect claims may be returned to you.
By signing this claim form and/or submitting actual receipts, I acknowledge and agree that:
• the information provided is complete and accurate to the best of my knowledge;
• RBC Insurance is authorized to exchange information with other parties as needed to administer this benet claim and/or to conrm the accuracy of this information;
• eligibility for Cost Plus benets is determined by the Plan Administrator, and the Plan Administrator is responsible for verifying employee and dependent eligibility before
a claim is submitted;
• RBC Insurance will rely upon the Plan Administrator to obtain the plan member’s consent to collect, use and disclose information with RBC Insurance, its agents and
service providers for the purpose of administering the Cost Plus claim.
Date Signature of Plan Administrator Print Name and Title
® / ™ Trademark(s) of Royal Bank of Canada. Used under licence.
RBC Life Insurance Company, 8677 Anchor Drive, PO Box 1600, Windsor Ontario N9A 0B3
1-855-264-2174
www.rbcinsurance.com/group-benets
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Cost Plus Claim Form WHEN IS COST PLUS (RBC Insurance)

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Completed 21 May 2021

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