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Get Extended Health Care Claim Online 2018-2024

Original receipts will not be returned. 1 Plan member information Plan contract number Plan member certificate number Plan sponsor Plan member name (first, middle initial, last) Daytime phone number ( Date of birth (dd/mmm/yyyy) ) Plan member address (number, street and apt.) City/Town Province Postal code 2 Workers compensation board Are any of the expenses associated with a work related incident AND eligible for workers compensation benefits? 3 Coordination of benefits Are y.

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