Health Claim Statement: Submitting for Payment and Tax Purposes

Individual Insurance, PO Box 670, Stn. Waterloo, Waterloo ON N2J 4B8 Questions regarding your claim or estimate? Please contact us at 1-800-268-3763 Monday to Friday 8am-8pm ET or [email protected].IMPORTANT Please ensure all claim forms are signed when submitting for payment. Please keep this document for income tax purposes, or if coordinating benefits with another plan. This document is sufficient for income tax purposes. Plan member name:BEDEAU J Plan number:177792 5 Identification number:6822842161 Deductible year-end date: J BEDEAU 904-35 WYNFORD HEIGHTS CRESCEN NORTH YORK, ON M3C 1K9 Invoice number: P900916145 CLAIMANTDATE OFSERVICEDESCRIPTIONBENEFITCODE/DINAMOUNTCLAIMEDAMOUNTALLOWEDDEDUCTIBLECO-PAYMENTPAID BY OTHER INSURANCE AMOUNTPAYABLEEXPL.CODE * JULESMar. 24,2022MASSAGE THERAPIST 0024$25.00$25.00$0.00$0.00$0.00$25.00 Amount payable$25.00 Statement date: Apr. 01, 2022Amount of direct deposit$25.00