Remittance Form

Employee and company details

Your company's name*:

E-mail address to which your copy of this form will be sent*:

In which province is your company based?*:
AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Company account number (optional):

Employee name: (Name of person enrolled in the plan, rather than dependants.)*

Reimbursement payable to: (employee name or business name)*

Telephone*:

Optional:

If you have a new address, enter it here:

City:

Province:
AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Postal code:

This is the company's addressThis is the employee's address

Claims submitted via this form constitutes consent to continue to contact you/your business by email.

List expenses

Please ensure that the amounts you have entered consist of numbers only, with no currency symbols or commas.

Miscellaneous notes:

Total Current Claim:

Payment to HealthLink Benefits can be made by your company through email money transfer or pre-authorized debit. (Instructions will be included in the approval e-mail.)

Receipts

Please ensure all fields marked with an asterisk have been filled in.

This form will be e-mailed to you. If you would like a printed copy of the submitted form, we recommend printing the e-mail.

After we have reviewed your receipts, your company will receive another e-mail confirming the total owing.

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