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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
