Company Name

Borden Cold Storage Limited

Employees Name

Wellknit Certificate Number

Ron Holmes

1100005202

Date of Birth (YYYY / MM / DD)

1971/03/08

Employees Address

Telephone No.

No. and Street

City

Province

Postal Code

2969 Kingsway Dr. Apt 1109

Kitchener

ON

N2C 2H7

226.243.2129

When mailing the claim form, please attach the original paid receipts and other required documents* for all expenses claimed
on this form. Paid receipts must include the name and address of the licensed healthcare professional providing or prescribing
the goods or services for which you are claiming. All original receipts are part of our records and will not be returned. Please
retain copies of your receipts for your records.
When sending a claim form by email, please scan your signed claim form, all the receipts and all other required documents*
for the expenses claimed on this form and attach all files to the email message. Make sure you keep the original receipts in
case you are asked to provide them at a later date for verification purposes.
* Co-ordination of Benefits
o Have you (or your dependent) any other coverage which has paid some or all, of this claim?
Yes
No
If Yes, please provide the Explanation of Benefits showing payment details.
Do not submit claims if:
o your pharmacy or dentist has already sent them in electronically.
o you do not have sufficient funds in your account.
There is a $5.00 processing fee for each claim. A claim is defined as all transactions for one certificate holder (employee,
spouse and/or dependents) that are submitted on the same date.
Claims are processed every 2 weeks. Payments are made by direct deposit to your bank account.
Wellknit reserves the right to reverse payments made in error.
PATIENT NAME

RELATIONSHIP TO EMPLOYEE

DATE OF BIRTH

NUMBER OF
RECEIPTS

YYYY / MM / DD

Jennifer Holmes

wife

1978/08/12

TOTAL SUBMITTED
EXPENSES

248.36

I confirm that the Health Care professional providing the product or service has verified that none of these expenses are solely for cosmetic purposes.
I certify that the above information is true, correct and complete. I authorize Wellknit Services Inc. ("Wellknit") to collect and use personal information about me
and/or my eligible dependents to process this claim and administer my benefit plan. I am aware Wellknit will keep my personal information confidential and
safeguarded. I am aware that Wellknit will only release personal information to my eligible dependents specific to their benefit entitlements. I understand that my
personal information (and the personal information of my eligible dependents) may only be shared with health care practitioners, medical facilities, providers of
health care/dental services or benefits administration services, provincial health insurance plans, insurance carriers, government agencies, and auditing or
independent investigative organizations in order to verify eligibility for my benefit entitlements.

Employees Signature

Send by mail: Please mail this signed claim form,

the receipts and other required documents* to:
Wellknit Services Inc.
1-1331 Crestlawn Drive
Mississauga, ON L4W 2P9

Date:

OR

YYYY

MM

DD

Send by email: Please scan this signed claim form,

the receipts and other required documents* and send
them by email to:
Wellknit Services Inc.
claims@wellknit.ca

Rev. 12 / 12