Summary: 1. Complete "Employee Statement" in full and send completed form to Great-West Life Assurance Company (see page 2).
2. Attach the original bills and receipts for all expenses and itemize them by providing all the information requested. Photocopies and
carbon copies are not acceptable; please make copies for your own records.
3. Prescription drugs are the only drugs for which reimbursement will be made. Prescription number and the name of the drug or D.I.N.
(Drug Identification Number) must be shown on all receipts. Please ensure that your pharmacist is aware of this requirement.
4. Expenses paid under this plan are not eligible for federal income tax exemption.
CLAIM FOR GROUP SUPPLEMENTARY HEALTH BENEFITS
PART 1 - FOR CLAIM SUBMISSION INSTRUCTIONS - SEE PAGE 2
GROUP POLICY NO. EMPLOYEE NUMBER (STAFF NO.) EMPLOYEE SURNAME INITIALS
1 3 9 0 4 6
PLEASE SEPARATE AS SHOWN ALL ELIGIBLE EXPENSES - SEPARATE TOTAL FOR SELF AND EACH DEPENDENT
DATE OF BIRTH
NAME OF PATIENT
DAY MONTH YEAR
TOTAL DRUG CHARGES TOTAL OTHER CHARGES
1. If claim is for child age 21 or over indicate Student Disabled