Fill and Sign the Federal Direct Consolidation Loan Application and Promissory Note William D Ford Federal Direct Loan Program Form

La Capitale Insurance and Financial Services Inc. 625 Saint-Amable St P.O. Box 1500 Quebec QC G1K 8X9 INFORMATION ON THE PARTICIPANT A. DENTAL INSURANCE CLAIM FORM If the information contained in Section A is incorrect or incomplete, please fill in Section B. B. Name: Address: Postal Code: Group: Employer: Identification No.: Phone: Group: Employer: Identification No.: IMPORTANT 1. For dependent child aged 18 to 26 years old, fill in section 2 on this form. 2. If dental services are necessary as the result of an accident, fill in section 3 on this form and include the x-ray(s). 3. Your claim form must be filled in within 12 months from the date dental expenses were incurred and services received. 1- INFORMATION ON THE PARTICIPANT: Employer’s name: Participant’s telephone number: at home at work Participant’s date of birth INFORMATION ON THE PATIENT: Relationship with the participant: o spouse o other Patient’s date of birth Y M D o child Y M D Are any dental benefits or services provided under any other group insurance or dental plan, or government plan? o No Policy No.: Spouse’s date of birth Y M D Name of insuring agency: First name o Yes 2- STUDENT CERTIFICATE FOR CHILD AGED OVER 17 OR 20 YEARS OLD ACCORDING TO YOUR POLICY I hereby certify that my child sity Name of institution for the is unmarried and attends the secondary school, college or univer- First name o fall session Year , or o winter session Year , as a day student on a full time basis. 3- DENTAL SERVICES REQUIRED AS THE RESULT OF AN ACCIDENT o No o Yes If yes, indicate the date, give some details, and enclose the X-RAY(S). I AUTHORIZE THE RELEASE OF ANY INFORMATION OR RECORDS REQUESTED IN RESPECT OF THIS CLAIM TO THE INSURER AND CERTIFY THAT THE INFORMATION GIVEN IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. Y ✂ M D ALL INFORMATION RECORDED ON THIS FORM IS CONFIDENTIAL. ✂ Participant’s signature (DENTAIRE-A) CPRDA1 (2013-01-09) ✂ DENTAL CLAIM FORM STANDARD FORM APPROVED BY QUÉBEC DENTAL SURGEONS ASSOCIATION D E N T I S T Name: Patient’s Last Name Phone No.: Licence: N.B.: An official receipt or the professional’s seal is required for reimbursement. Date of treatment Year Month Day Internat Tooth Code Procedure code Surface or Sextant Dentist’s fee Phone No. Total Charge Total Fees Submitted This is an accurate statement of services performed and fees charged, or of services to be performed and fees to be charged in the case of a treatment plan except errors and omissions. Date Dentist’s signature o I understand that the fees listed in this claim may not be covered by or may exceed my plan benefits. I understand that I am financially responsible to my dentist for the entire cost of the treatment. I authorize release of the information contained in this form to my insurance company or plan administrator. Laboratory Charge Province Postal Code Postal Code: Apt. City City, province: First Name(s) Address Address: Year Month Day TOTAL DUPLICATE FORM o Treatment Plan This estimate is valid for 60 days only. Fees do not cover complications that may occur during and after treatment. Laboratory costs are approximate. Reserved for dentist’s use for additional information on diagnosis, procedures complications and special conside­ ations. r IMPORTANT The participant must duly fill in the reverse of this form and sign it. N.B.: An official receipt or the professional’s seal is required for reimbursement. No date of treatment should appear on this form. Signature of patient (or parent/guardian) (DENTAIRE2-A)CPRDA2 (2013-01-09)