PLEASE SUBMIT COMPLETED CLAIM FORM TO

1 GROUP DENTAL CLAIM FORMPART 1 - DENTISTUNIQUE 'S OFFICE ACCOUNT HEREBY ASSIGN MY BENEFITS PAYABLE FROM THIS CLAIMTO THE NAMED DENTIST AND AUTHORIZE PAYMENT DIRECTLYLAST NAMEGIVEN NAMETO CODESTTPHONE OF SUBSCRIBERFOR DENTISTS USE ONLY - FOR ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURES OR SPECIALI understand the fees listed in this CLAIM may not be covered by or may exceed my plan understand I am financially responsible to my dentist for the entire treatment. I acknowledgethat the total fees of $_____ is accurate and has been charged to me for services authorize release of the information contained in this CLAIM form to my insuring company/planadministrator for the purpose of processing my of Patient (Parent / Guardian)OFFICE VERIFICATIONDUPLICATE FORM DATE OF SERVICE PROCEDUREINT.

2 TOOTH TOOTHDENTIST'S LABORATORY Day Mo. Year CODE CODESURFACES FEE CHARGE TOTAL CHARGESPLEASE SUBMIT COMPLETEDCLAIM FORM TO:Manion, Wilkins & Associates - 21 Four Seasons PlaceEtobicoke, OntarioM9B 0A6 Phone: (416) 234-5044 THIS IS AN ACCURATE STATEMENT OF SERVICES PER-Toll Free: 1-800-263-5621 FORMED AND THE TOTAL FEE DUE AND PAYABLE, E & FEE SUBMITTED:PART 2 - EMPLOYEE INFORMATIONCERTIFICATE # 's nameDate of 's AddressStreetCity/TownPhone NumberIs this an address change?Yes you or your dependent(s) have any other Insurance to cover these benefits?YesNoIf yes, PLEASE specifyInsurance Company NamePolicy NumberCertificate denture, bridge or crown, is this an initial placement?

3 YesNoIf initial placement, advise the date teeth were extracted and all other missing replacement, advise date of prior placement and reason for this CLAIM is for a spouse or child, complete the following 's Date of to Member Spouse Child Day this dependent working?YesNoIs this dependent attending school?YesNoIf YES give name of employer or treatment is due to an accident, indicate date of accident and hereby certify that the above statements are true, accurate and complete to the best of my knowledge and belief. I understand that thePlan Administrator will use the information provided by me on this CLAIM form strictly to process my CLAIM .

4 I hereby authorizethe Plan Administrator to evaluate or investigate my CLAIM , and release my personal information (including health information) to qualifiedthird parties solely for the purpose of conducting such evaluations or investigations, and only to the extent required for such hereby authorize my employer, any licensed dentists or other health professionals, any medical facility, any insurance company orgovernment body, and any other person or institution to release relevant information to the Plan Administrator solely for the purpose ofprocessing this CLAIM . A photocopy of this release shall be as valid as the of EmployeeDatePlan No.