Summary: STATEMENT OF CLAIM
Benefitsfor medicalexpensesincurredoutsideof Canadaaresubjectto thecoveragelimitationsin your groupinsuranceplan,as
well aspaymentby yourprovincialhealthplanandcoordinationwith otherinsurancecarriers. Completionof this claim fonn and
the governmentassignmentfonn(s) will allowusto payeligible claimsandcoordinatebenefitsfor your out-of-countrymedical
expensesdirectly with yourprovincial healthplanandotherinsurancecarriersonyourbehalf.
Please fully complete both sides of this statementof claim, including the "Statementof Other Insuranl;e" shown on the reverse, and
the attached go'fernment assignmentform(s). Your claim cannot beconsidered unlesstheseforms are completed in full. Send these
forms and all your original receipts to Great-West Life, Attention Out-Of-Country Claims Department,P.O. Box 6000, Winnipeg,
Manitoba, Canalda,R3C 3A5. Your receipts will beretained by Great-WestLife. In-Canada expensesshould beclaimed separately.
If you have any questions,please contact Great-WestLife directly at 1-800-957-9777and askto speai<:to a client service rep~senta-
tive in the Out-Of-Country Claims Department. --
Employer Queen's UniversitvPlanNumber 139Q46 I.D.Number
I authorizethel-eleaseof anyinformationor record(s)requestedin respectof this claimto Great-WestLife or its agentsandcertify
thatthe informationgivenhereinis true,correct,andcompleteto the bestof myknowledge.