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EHC-E-11-10
Extended Health Care Claim Form
1 | Information about you be sure to fully complete this section
Use this form for all medical expenses and services.
For dental expenses, please use the Dental Claim Form.
Please print clearly and be sure all sections are complete to avoid
delays in processing your claim.
Attach the original receipt for each expense claimed and keep
photocopies for your records.
Sign on page 2 and mail your claim to the address at the bottom
of page 2. Some plans allow claims to be submitted online at
www.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 | Complete this section if you or your spouse are covered under another plan
Send your claims to your own plan first. When you receive your claim statement, send a copy plus copies of your receipts to your spouse’s
plan to claim any unpaid amount.
Send your spouse’s claims to their plan first, then send a copy of their claim statement and receipts to your plan.
Send your children’s claims first to the plan of the parent whose birthday falls earlier in the year.
Is your spouse a member of another benefit plan?
m
No
m
Yes If yes, please provide details below.
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
X
Date (yyyy-mm-dd)
Are you also a member of another benefit plan?
m
No
m
Yes If yes, please provide details below.
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 | Information about your claim
List the names of all persons for whom you are claiming expenses. Add up all the receipts and insert the total amount claimed. Ensure each
receipt clearly indicates the type of expense being claimed.
Date of birth Full-time
Person for whom you are making the claim (yyyy-mm-dd) Relationship to you student Disabled Amount claimed
Last name First name
m Yes
m No
m Yes
m No
$
Last name First name
m Yes
m No
m Yes
m No
$
Last name First name
m Yes
m No
m Yes
m No
$
Last name First name
m Yes
m No
m Yes
m No
$
Total claimed
$
Are you attaching receipts for out-of-Canada expenses?
m
No
m
Yes
If yes, tell us the date of departure from claimant’s home province. Ensure the
currency and amount are clearly marked on each receipt. We’ll assess your claim
and convert the eligible expenses to Canadian dollars.
Are any of the expenses you’re claiming the result of a work injury?
m
No
m
Yes
If yes, did you submit your claim to the workers’ compensation plan in your province, if applicable?
m
No
m
Yes
Are any of the expenses you’re claiming the result of a motor vehicle accident?
m
No
m
Yes
If yes, did you submit your claim to the automobile insurance plan in your province, if applicable?
m
No
m
Yes
Date
(yyyy-mm-dd)
Out-of-Canada expenses claimed
$
For SLF use:
HCF
Clear
25180
Ryerson University
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EHC-E-11-10
4 | Authorization and Signature you must complete this section
I certify that all goods and services being claimed have been received by me and/or my spouse or dependents, if applicable.
I certify that the information in this form is true and complete and does not contain a claim for any expense previously paid
for by this or any other plan.
If this claim is being made on behalf of my spouse and/or dependents, I am authorized to disclose information about them,
for the purposes of underwriting, administration and adjudicating claims. I confirm that my spouse and/or dependents, if
any, also authorize Sun Life Assurance Company of Canada (“Sun Life”) to disclose information about their claims to me, for
the purposes of assessing and paying a benefit, if any, and managing my group benefits plan.
I authorize Sun Life and its reinsurers to collect, use and disclose information about me, and if applicable, my spouse and/
or dependents needed for underwriting, administration and adjudicating claims under this Plan to any other organization
who has relevant information pertaining to this claim including health professionals, institutions, investigative agencies and
insurers. I also understand that information pertaining to this claim may be reviewed in the event this Plan is audited.
In the event there is suspicion and/or evidence of fraud and/or Plan abuse concerning this claim, I acknowledge and agree
that Sun Life may investigate and that information about me, my spouse and/or dependents pertaining to this claim may be
used and disclosed to any relevant organization including regulatory bodies, government organizations, medical suppliers
and other insurers, and where applicable my Plan Sponsor, for the purpose of investigation and prevention of fraud and/or
Plan abuse.
If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable to
me under my benefit plan(s), and the collection, use and disclosure of information about this claim to other persons or
organizations, including credit agencies and, where applicable, my Plan Sponsor for that purpose.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect
for the continued administration of this Plan.
Any reference to Sun Life Assurance Company of Canada or the Plan Sponsor includes their respective agents and service providers.
Member’s signature
X
Date (yyyy-mm-dd)
Respecting your privacy
Your privacy is important to us. We may leverage our strengths in our worldwide operations and in our negotiated relationships with third-
party providers to help us service some of our customers. In some instances our employees, service providers, agents, reinsurers and any of
their service providers, may be located in jurisdictions outside Canada, and your personal information may be subject to the laws of those
foreign jurisdictions.
To find out about our Privacy Policy, visit our website at www.sunlife.ca, or to obtain information about our privacy practices, send a written
request by email to privacyofficer@sunlife.com, or by mail to Privacy Officer, Sun Life Financial, 225 King St. West, Toronto, ON M5V 3C5.
Questions? Please visit www.sunlife.ca or call our toll-free number 1-800-361-6212 Monday - Friday, 8 a.m. - 8 p.m. ET
Mailing instructions keep a copy of your claim form and receipts for your records
Mail your completed
form to the claims
office nearest you.
Sun Life Assurance Company
of Canada
PO Box 11658 Stn CV
Montreal QC H3C 6C1
Sun Life Assurance Company
of Canada
PO Box 2010 Stn Waterloo
Waterloo ON N2J 0A6
For SLF use:
HCF
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