CUPE Authorized Rep: Date:
DROP OFF Form & Receipts at
B111 KennethTaylor Hall, McMaster University
1280 Main St. W., Hamilton, Ontario L8S 4M4
Tel: 905-525-9140 ext. 24003 www.cupe3906.org
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
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
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)
McMaster University Employee No.
NOTE: This number MUST be shown
Please mail cheque to me (name above) at my home address below.
FOR REIMBURSMENT CHEQUE - please choose only one of the following 3 options:
B111 Kenneth Taylor Hall, McMaster University
1280 Main St. W., Hamilton, Ontario. L8S 4M4
Mail directly to medical practitioner. Name and address as shown on attached valid receipts.
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