Wellness Claim Form

GCIFM-7261 Wellness Benefit Reimbursement 1 of 4 04/23 Sun Life Assurance Company of Canada Wellness / Cancer Screening Claim Statement I nstructions The following benefits, subject to the election of your employer, may be covered under your Certificate. The Accident, Critical Illness, and Hospital Indemnity policies provide one Wellness Benefit per calendar year per covered person from the list of covered benefits. The Cancer policy provides one Cancer Screening Benefit per calendar year per covered person from the policy list of covered benefits. See the policy for details of covered items and services. Only tests and procedures listed in the policy are eligible for benefit payment. Complete a separate form for each family member and date of service. Complete all applicable sections. You must include the: • name of the provider of the service • type of service • date of service Submit this form to the address, fax number or e-mail address stated at the bottom of this form. Note: Some policies do not contain the Wellness Benefit. 1 | Employer infor m ation Employer name Policy number 2 | Insured information Insured name M F Social Security number Date of birth (mm/dd/yyyy) Insured street address City State Zip code Insured phone number E-mail address 3 | Claimant information Claiming benefits for: Insured Spouse Dependent child Check all the coverages in place for the insured on the service date of the screening: Accident policy Critical Illness policy Cancer policy Hospital Indemnity policy Claimant name M F Social Security number Date of birth (mm/dd/yyyy) Provider name Provider phone number Date of service (mm/dd/yyyy) Provider street address City State Zip code Claimant home phone number Claimant work phone number