Date:
CUPE Authorized Rep: Date:
DROP OFF Form & Receipts at
CUPE 3906
B111 KennethTaylor Hall, McMaster University
1280 Main St. W., Hamilton, Ontario L8S 4M4
Tel: 905-525-9140 ext. 24003 www.cupe3906.org
OR
Any questions call (Prosure Group) Tel: 416 - 609-0978 Ex 5332 Toll Free: 888 - 556-5559 Ex 5332 FAX: 416-609-9551
2225 Sheppard Ave East, Ste 1400, Atria III
Toronto, Ontario M2J 5C2
PLEASE PRINT FORM after completion then SIGN & DATE. I submit this claim in the knowledge that any false information
may result in my immediate disqualification from this benefit plan and could result in further legal proceedings.
SPENDING ACCOUNT & ENROLLMENT
Please include - Original receipts and/ or Explanation of benefits form from primary insurer.
CLAIMS CANNOT BE PAID WITHOUT THIS DOCUMENTATION
UNIT 1
CLAIM FORM
Sept.1, 2013 Version 2
(P L E A S E T Y P E O R P R I N T C L E A R L Y)
LAST or FAMILY NAME
FIRST NAME
HOME PHONE or CELL #
Email address
McMaster University Employee No.
Please mail cheque to me (name above) at my home address below.
FOR REIMBURSMENT CHEQUE - please choose only one of the following 3 options:
CUPE 3906
B111 Kenneth Taylor Hall, McMaster University
1280 Main St. W., Hamilton, Ontario. L8S 4M4
Mail cheque to:
Mail directly to medical practitioner. Name and address as shown on attached valid receipts.
Claimant
Name
Date of Birth
Information
mmm/ day / year
Type of Claims
(i.e. Rx Drugs, Vision,
Dental, Other)
$ Amount
OR
OR
Prosure Group Administrators Ltd.
Name as above
SEND CLAIM FORM & RECEIPT(S) TO
TOTAL CLAIMS - Maximum allowable is $250 per person, (including Dependents) every 24 months
SELF
Spouse
Dependent 1.
Dependent 2.
Member Signature:
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