Transcription of UHIP Claim form
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UHIP Claim form
UHIP Claim formAll claims must be submitted to Sun Life Assurance Company of Canada at the address below no more than TWELVE MONTHS following the date on which the expenses are incurred . Sun Life is the insurer and a member of the Sun Life group of companies. 1 | UHIP memberinformationUniversity namePolicy number50150 UHIP member identification number I I I I I I I I I I I Last nameFirst nameMiddle nameDate of birth (dd-mm-yyyy) Male FemaleGender Telephone number Email addressCanadian address (street number and name)Apartment or suiteCityProvincePostal codeDo you or your dependents have additional Health coverage with Sun Life Assurance Company of Canada? Yes If yes, please provide Policy number Member identification number No 2 | ClaimantinformationLast nameFirst nameDate of birth (dd-mm-yyyy) Son DaughterRelationship to UHIP memberMemberSpouse 3 | UHIP memberauthorizationandsignature(Amembers ignatureisrequiredwhenthereimbursementis tobemadetotheUHIP member.)
UHIP Claim form All claims must be submitted to Sun Life Assurance Company of Canada at the address below no more than TWELVE MONTHS following the date on which the expenses are incurred.
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