Merit Contractors Association Benefit Plan Assignment Of Benefits Form printable pdf download

Merit Contractors Association Benefit Plan Assignment Of Benefits Form

Merit Contractors Association Benefit Plan

Assignment of Benefits Form

This form is to be used when a member of the Merit Contractors Association Benefit Plan

wishes to assign payment of their benefit claim to a service provider. In order to do so,

you must have the agreement from the service provider.

Please complete the form below and attach it directly to the claim form. You must

complete this form each time you wish to assign payment of your benefit claim.

Merit Plan Member’s Last Name

Merit Plan Member’s First Name

___________________________

______________________________

Merit Plan Member’s ID Number

Merit Plan Member’s Phone Number

___________________________

______________________________

I, __________________________, assign benefits from the attached claim to be

payable to ___________________________(the provider of the service).

Merit Plan Member’s

Date: ___________________

Signature: _________________________________

Send completed form (together with the claim form) to:

Great-West Life

Winnipeg Benefit Payments

P.O. Box 3050

Winnipeg, MB R3C 4E5

If you have any questions about assignment of benefits, please contact Mercon Benefit

Services in Edmonton at 455-5845 or toll-free at 1-877-263-7266. They may also be

contacted by email at .

February 2007

Merit Contractors Association Benefit Plan Assignment Of Benefits Form