Plan Member Name Date of Birth
Plan Member Home Mailing Address
STREET CITY/TOWN PROVINCE POSTAL CODE
Group or Plan Name Plan Number ID Number
Type of Eligible Expenses:
n $
n $
n $
n $
n $
n $
n $
n $
n $
n $
Total receipts included
Total Claim $
Employee’s Signature Date
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Health SolutionsPlus
HEALTHY LIVING ACCOUNT
INSTRUCTIONS
1. Complete part 1 and 2 of this form in full.
2. Sign and date the form.
3. Please retain copies for your files as original receipts will not be returned.
4. Send to the appropriate Benefit Payment Office for your plan. See PART 3.
All claims under this group benefits plan are submitted through
the plan member. We may exchange personal information about
claims with the plan member or a person acting on their behalf
when necessary to confirm eligibility and to mutually manage the
claims.
PART 1: PLAN MEMBER’S STATEMENT
At Canada Life, we recognize and respect the importance of privacy. Personal information that we collect will be used for the purposes of assessing your claim
and administering the group benets plan. For a copy of our Privacy Guidelines, or if you have questions about our personal information policies and practices
(including with respect to service providers), write to Canada Life’s Chief Compliance Ofcer or refer to www.canadalife.com.
I also consent to the use of my personal information for Canada Life and its afliates’ internal data management and analytics purposes.
I authorize Canada Life, any healthcare provider, my plan administrator, other insurance or reinsurance companies, administrators of government benets
or other benets programs, other organizations, or service providers working with Canada Life, located within or outside Canada, to exchange personal
information when necessary for these purposes. I understand that personal information may be subject to disclosure to those authorized under applicable law
within or outside Canada.
I certify that I am claiming expenses that were incurred by myself or an eligible dependent.
PART 2: CLAIM INFORMATION
Include receipts with your claim for reimbursement. Please indicate (✔) the expense and amount you are claiming.
Certified Instruction (e.g. personal trainer) or instructed classes at a fitness facility (e.g. aerobics / pilates / cycle / dance)
Exercise equipment (new or used), repairs and extended warranty
Weight Management programs (food excluded)
Vitamins / Minerals / Supplements / Natural Health Products / Herbal remedies
Alternative healing therapies (e.g. Reiki / Shiatsu Therapists)
Health / Stress Management programs (e.g. spa / wellness retreats)
Smoking Cessation programs and products
Fitness Centre membership fees (Drop in / Monthly / Annual Fee)
Athletic Facility fees, including Sports and Golf / Country Club fees (receipt must include the name of facility or league)
Other: Please describe
HEALTH SOLUTIONSPLUS - HEALTHY LIVING ACCOUNT EXPENSES ARE REIMBURSED AT 100% OF ELIGIBLE EXPENSES,
SUBJECT TO AVAILABLE CREDITS. ALL REIMBURSED CLAIMS WILL BE TREATED AS A TAXABLE BENEFIT.
PART 3: SUBMITTING YOUR CLAIM
Please send your claim to the Benefits Payment Office below: If blank, please consult your plan administrator for the address.
Health SolutionsPlus Questions?
Call Toll Free: 1.877.883.7072
Winnipeg Benefit Payments
PO Box 3050 Station Main
Winnipeg MB R3C 0E6
www.canadalife.com
Deaf or hard of hearing and require access to a telecommunications relay service?
Please contact us:
TTY to Voice: 711
Voice to TTY: 1-800-855-0511
M7311-2/20
© The Canada Life Assurance Company, all rights reserved. Canada Life and design are trademarks of The Canada Life Assurance Company.
Any modification of this document without the express written consent of Canada Life is strictly prohibited.
