- Fill out and sign the form
- Gather original supporting documents
- Send everything to the address indicated on the form
Keep copies of all correspondence for at least 12 months.
- Originals will not be returned.
Wellness account claim - Plan member - 17111E (PDF, 1.1 MB) Opens in a new window.
This form is used to submit claims for expenses and services related to the wellness account, if this coverage is offered under your plan.
The request must be sent
within the time limit specified in your employee booklet. To have your claim processed faster, you can use our e-claims services on our
plan member’s secure site External link. Opens in a new window..