Fillable Group Benefits Dental Claim Form (Page 2 of 2) in pdf

part 4 - plan sponsor autHorization (

)

only if required

employment Date ____________________ employee’s/Member’s effective Date ______________________

Dependent’s effective Date _____________________

MMM/DD/YYYY

Termination Date (if applicable) ____________________

Retirement Date _____________________

Status

Single

Couple

Family

MMM/DD/YYYY

Signature of Authorized Official ____________________________________________________________________________

Date ____________________________

MMM/DD/YYYY

part 5 - priVaCy anD autHorization

Co-operators life insurance Company privacy statement

Co-operators Life Insurance Company is committed to protecting the privacy, confidentiality, accuracy and security

of the personal information that it collects, uses, retains and discloses in the course of conducting business.

I certify that the information contained herein is true, complete and accurate and that each of the listed expenses was purchased and/or incurred in connection with

medical treatment of the above-named individuals. I acknowledge that the submission of false or incomplete information may result in the delay or denial of this claim. I

authorize any physician, dentist or any health care provider and/or facility, any insurance company, benefit service provider and any other person or organization

having any medical or other relevant personal information regarding me or my spouse and/or dependent to release to and exchange with Co-operators Life

Insurance Company, the group plan administrator or their representatives and/or agents any and all information necessary to investigate and confirm the accuracy

and validity of this claim, determine eligibility for benefits and/or administer the claim and group benefit plan. I confirm that I am authorized to act on behalf of my

spouse and/or dependents for such purposes. Any copy of this authorization shall be as valid as the original.

In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning this claim, I acknowledge and agree that Co-operators Life Insurance Company

may investigate and that information about me, my spouse and/or dependents pertaining to this claim may be used and disclosed to any relevant organization

including regulatory bodies, government organizations, medical suppliers, and other insurers, and where applicable my Plan Sponsor, for the purpose of

investigation and prevention of fraud and/or plan abuse.

If Co-operators Life Insurance Company pays me an amount that exceeds the benefit(s) to which I am entitled under my plan (the Overpayment Amount), then I

acknowledge and agree that: (a) I am indebted to Co-operators Life Insurance Company for the Overpayment amount (b) Co-operators Life Insurance Company

has the right to recover the Overpayment Amount through any means available by law, and (c) Co-operators Life Insurance Company will offset any benefits payable

to me by the Overpayment Amount until Co-operators Life Insurance Company has recovered the Overpayment Amount in full.

Plan Member Signature ______________________________________________________________________________ Date _________________________________

MMM/DD/YYYY

Co-operators Life insuranCe Company

LC231 (09/11)

1920 CoLLege avenue regina sK

s4p 1C4

pg 2 of 2