Transcription of Extended Health Care Claim Form - Sun Life Financial
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Extended Health Care Claim Form - Sun Life Financial
Page 1 of 2 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 number Member ID numberYour plan sponsor/employer Preferred language of correspondencem English m FrenchYour last nameFirst namem Malem FemaleDate of birth (yyyy-mm-dd) Daytime phone number Your address (street number and name)Apartment or suiteCity
Page . 1. of 2 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
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