Fillable TWSA Claim Form

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TWSA Claim Form

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The TWSA Claim Form form is 2 pages long and contains:

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  • 27 check-boxes
  • 158 other fields

Country of origin: CANADA
File type: PDF

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Page 1 of 3
PSA-151610-E-12-17 (G6736-E)
Taxable Wellness Spending Account
(Personal Spending Account)
1 | Information about you
Be sure to fully complete
this section.
• Sun Life Assurance Company of Canada, a member of the
Sun Life Financial group of companies, is committed to
keeping your information confidential.
• Please print clearly and be sure to complete all sections of your
Taxable Wellness Spending Account claim form.
• Attach the original receipt for each expense claimed and keep
photocopies for your records.
• Sign Section 3 and mail your claim to the address at the end of
this form.
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
2 | Details of claims
Ensure each receipt clearly indicates the type of expense being claimed.
Attach original receipts or if this claim has been submitted under another plan, attach the original claim statement from the plan and copies of the receipts.
Provider name Date incurred Amount
(if not clearly indicated (yyyy-mm-dd) claimed
on receipt)
Fitness-related services
 fitness club memberships _____________________________ _______–_____–_____ $____________
 registration fees for fitness-related programs or lessons such
as yoga, aerobic classes, dance, swimming, sailing lessons _____________________________ _______–_____–_____ $____________
 sports team memberships and registration fees _____________________________ _______–_____–_____ $____________
 annual memberships, such as golf, curling, skiing etc. _____________________________ _______–_____–_____ $____________
 court fees, green fees, ski passes, lift tickets and
race registrations _____________________________ _______–_____–_____ $____________
 personal trainers, fitness consultants, lifestyle
consultants and exercise physiologists _____________________________ _______–_____–_____ $____________
Fitness equipment
 durable equipment eg: treadmills, exercise bikes and
universal gym _____________________________ _______–_____–_____ $____________
 sporting equipment, eg: Skates, roller blades, bicycles,
athletic footwear, hiking boots, curing equipment, tennis
racquets, golf clubs, safety helmets, snow gear, table tennis
tables, canoes, kayaks and paddleboards _____________________________ _______–_____–_____ $____________
 athletic gear, eg. hiking backpacks, running jackets _____________________________ _______–_____–_____ $____________
 heart rate monitors/fitness watches –
fitbit, apple watch, fuelband, garming forerunner _____________________________ _______–_____–_____ $____________
Health-related services
 weight management programs (excluding food) _____________________________ _______–_____–_____ $____________
 smoking cessation programs _____________________________ _______–_____–_____ $____________
 nutrition programs and counselling _____________________________ _______–_____–_____ $____________
 maternity services (prenatal classes and mid-wife services) _____________________________ _______–_____–_____ $____________
 alternative health practitioner eg: reflexologist, iridologist,
herbalist, homeopath, athletic therapist, Chinese medical
practitioner, Shiatsu therapist, osteopathic practitioner,
acupressurist ______________________________ _______–_____–_____ $____________
 stress management programs _____________________________ _______–_____–_____ $____________
Contract number
151610
Member ID number Your plan sponsor/employer
University of Guelph
Your last name First name
Male
Female
Date of birth (yyyy-mm-dd)
– –
Your address (street number and name) Apartment or suite City
Province Postal code Preferred language of correspondence
English French
Daytime phone number
– –
For SLF use:
HCF
Clear
Page 2 of 3
PSA-151610-E-12-17 (G6736-E)
Provider name Date incurred Amount
(if not clearly indicated (yyyy-mm-dd) claimed
on receipt)
 spiritual/wellness retreats (cost of program but excludes
cost of travel & accomodations) _____________________________ _______–_____–_____ $____________
 cholesterol and hypertension screening _____________________________ _______–_____–_____ $____________
 health assessments _____________________________ _______–_____–_____ $____________
 allergy tests _____________________________ _______–_____–_____ $____________
 vitamins & supplements, including herbal products _____________________________ _______–_____–_____ $____________
 other alternative wellness services: Reiki, Ayurvedic medicine,
touch therapy, Rolfing and light therapy ______________________________ _______–_____–_____ $____________
Insurance premiums
 insurance premiums paid for Critical Illness,
Life Insurance and Long Term Care _____________________________ _______–_____–_____ $____________
Work-life balance
 child care expenses _____________________________ _______–_____–_____ $____________
 elder care expenses _____________________________ _______–_____–_____ $____________
Other services
 hobby and general interest classes/courses and supplies not
related to professional development _____________________________ _______–_____–_____ $____________
 services of professionals eg: Lawyers, financial planners,
chartered accountants, investment advisors
_____________________________ _______–_____–_____ $____________
Are you attaching receipts for out-of-Canada expenses?
Ensure the currency and amount are clearly marked on each
receipt. We’ll process your claim and convert the eligible
expenses to Canadian dollars as of the
date of processing.  No  Yes
2 | Details of claims (continued)
3 | Authorization and signature
You must complete
this section.
Fraudulent claims are very
costly for all participants
in benefit plans. As
Administrator of this Taxable
Wellness Spending Account,
we may check the accuracy
of the information given in
support of your claim.
I certify that I have received all goods or services being claimed. 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. I certify that these expenses qualify for reimbursement under my
Taxable Wellness Spending Account.
I authorize Sun Life Assurance Company of Canada, its agents and service providers to collect,
use and disclose information about me, needed for administration and processing claims under
this Taxable Wellness Spending Account with any other person or organization who has relevant
information pertaining to this claim. I understand that information pertaining to this claim may
be reviewed in the event this Taxable Wellness Spending Account plan is audited.
I understand that I am responsible for the outcome of any tax consequences that may arise from
being reimbursed for these expenses. I also understand that my plan sponsor may have access to
an itemized listing of claims submitted by me under my Taxable Wellness Spending Account for
the purposes of payroll-related taxes and deductions, tax slip preparation or other administrative
reporting and plan management.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original.
Member’s signature
X
Date (yyyy-mm-dd)
– –
For SLF use:
HCF
Page 3 of 3
PSA-151610-E-12-17 (G6736-E)
Mailing instructions
–
keep a copy of your claim form and receipts for your records
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
Email your completed
form and supporting
documents to
myclaims@sunlife.com.
You can mail your
completed form and
supporting documents
to the Sun Life claims
office nearest you.
Respecting your privacy
Respecting your privacy is a priority for the Sun Life Financial group of companies. We keep in confidence
personal information about you and the products and services you have with us to provide you with
investment, retirement and insurance products and services to help you meet your lifetime financial
objectives. To meet these objectives, we collect, use and disclose your personal information for purposes that
include: underwriting; administration; claims adjudication; protecting against fraud, errors or
misrepresentations; meeting legal, regulatory or contractual requirements; and we may tell you about other
related products and services that we believe meet your changing needs. The only people who have access to
your personal information are our employees, distribution partners such as advisors, and third-party service
providers, along with our reinsurers. We will also provide access to anyone else you authorize.
Sometimes, unless we are otherwise prohibited, these people may be in countries outside Canada, so your
personal information may be subject to the laws of those countries. You can ask for the information in our
files about you and, if necessary, ask us in writing to correct it. To find out more about our privacy practices,
visit www.sunlife.ca/privacy.
For SLF use:
HCF
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TWSA Claim Form

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Completed 1 May 2020

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