Group Benefits
Taxable Wellness Spending Account (WSA)
1 Plan member information
Plan contract number
Plan member name (first, middle initial, last)
The Manufacturers Life Insurance Company
GL5382E(87222) (12/2015)
2 Claims confirmation
I certify that I have received all goods or services claimed and that the information provided for this claim is true
and complete and represent no duplication of claims previously submitted to any plan. I authorize Manulife to
collect, use, maintain and disclose personal information relevant to this claim (“Information”) for the purposes of
determining eligibility, administration of coverage, payment of this claim, Group Benefits plan administration, audit
and the assessment, investigation and overall management of this claim (“Purposes”). I authorize any person or
organization who has Information relevant to this claim, including health professionals, facilities or providers, club
operators, professional regulatory bodies, any employer, group plan administrator, insurer, investigative agency,
and any administrators of other benefits programs to collect, use, maintain and exchange this information with
each other and with Manulife, and/or its service providers, for the Purposes. I authorize Manulife to disclose to
my employer benefit amounts paid from the plan for tax reporting purposes. I understand that eligible expenses
reimbursed under the Taxable Wellness Spending Account (“WSA”) are defined by my Plan Sponsor and
determination for eligibility is wholly within my Plan Sponsors’ discretion. I understand that eligible expenses
reimbursed under the WSA will be added to my T4, by my employer, as taxable income in the year it’s paid.
I understand that reimbursement of these expenses represents a taxable benefit to me and I am responsible for
payment of any income tax on these amounts. I agree a photocopy or electronic version of this authorization is
valid. I understand that Manulife’s Privacy Policy and Privacy Information Package are available at, or from my Plan Sponsor.
Signature of plan member Date signed (dd/mmm/yyyy)
Please sign here
3 Mailing instructions
Staple your receipts and, if applicable, your health or dental claim form(s) and insurance carrier's
claim statement(s)/explanation of benefit form(s) to the back of the claim form.
Place your completed claim form in an envelope and mail to:
PO BOX 1653
Date of birth (dd/mmm/yyyy)
City or town Province Postal codePlan member address (number, street and apt.)
Plan member certificate number
Total amount of ALL receipts submitted:
Any Information provided to or collected by Manulife in accordance with this authorization, will be kept in a Group
Benefits health file. Access to your Information will be limited to:
Manulife employees, representatives and service providers in the performance of their jobs;
persons to whom you have granted access; and
persons authorized by law.
You have the right to request access to the personal information in your file, and, where appropriate, to have any
inaccurate information corrected.
Plan sponsor
Western University
This benefit is for Plan Members only. This form is to be completed by the plan member. Receipts must be attached for all expenses.
(Please attach to the back of this form.)
Please retain copies for your files as receipts will not be returned.
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