To submit this claim form, you can mail it to The Empire Life Insurance Company at Group Health Claims, 259 King St East, Kingston ON K7L 3A8. Alternatively, you may submit your claim electronically through the designated online portal or via email at group.csu@empire.ca. Ensure to include all necessary documents and receipts to facilitate prompt processing.

Important dates for submitting claims include deadlines specific to your group insurance plan. Check with your employer or plan administrator for exact submission dates to ensure timely processing.

The purpose of this form is to facilitate the reimbursement of healthcare and dental expenses covered under the extended health benefits plan. It streamlines the claims process for insured members, ensuring that eligible expenses can be claimed effectively. By providing detailed information and required documentation, users can receive prompt financial assistance for their medical costs.

• 1. Personal Information: Includes fields for policy details, contact information, and accident-related queries.
• 2. Claim Submission: Provides clear instructions on how to submit claims, including necessary attachments.
• 3. Payment Options: Allows users to select preferred methods for claim payment and direct deposit.
• 4. Certification: A section for the insured to certify the validity of submitted claims and authorize information exchange.
• 5. Signature: A field for the insured's signature and date confirming the legitimacy of the claim.

Failing to submit this form may result in delayed reimbursements or denial of claims. It's crucial to provide accurate and complete information, as incomplete submissions can lead to further complications. Pay close attention to the requirements outlined in the submission guidelines.

• Delayed Payments: Claims may take longer to process, affecting timely reimbursements.
• Denial of Claims: Incomplete forms may be rejected, leading to loss of benefits.
• Additional Documentation Requests: Insurers might require further information, prolonging the claims process.

• 1. Medical Expenses: To claim reimbursement for healthcare costs associated with treatments or services.
• 2. Dental Claims: To submit claims for dental services expenses incurred by the insured.
• 3. Coordinating Benefits: If you have coverage from multiple providers, this form assists in managing claims.
• 4. Tracking HCSA Expenses: To maintain a record of expenses eligible for reimbursement from the Health Care Spending Account.
• 5. Dependants' Claims: For claiming eligible expenses incurred by insured dependants.