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Get and Sign Manulife Affinity Markets Extended Health Care Claim Form 2011
Town
Province
Are these expenses eligible for coverage under any type of
workers' compensation board?
Yes
Postal code
No
Are you, your spouse or dependants covered under any other plan for the expenses being claimed?
Yes
No
Spouse's date of birth
(dd/mmm/yyyy)
If "Yes," please retain photocopies of all receipts submitted with this claim for
submission to your secondary carrier. If this is your first claim, or if information
has changed, please provide the following:
Name of spouse's...
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