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Manulife Affinity Markets Extended Health Care Claim Form 2011

Manulife Affinity Markets Extended Health Care Claim Form 2011

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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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Manulife Affinity Markets Extended Health Care Claim Form 2011

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