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COST PLUS CLAIM FORM - MDM Insurance Services Inc.

COST PLUS CLAIM FORM PRIVACY STATEMENT MDM Insurance Services Inc. (“MDM”) is committed to protecting the privacy, confidentiality, accuracy and security

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Text of COST PLUS CLAIM FORM - MDM Insurance Services Inc.

COST PLUS CLAIM FORMPRIVACY STATEMENTMDM Insurance Services Inc. ( MDM ) 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 COMPLETE A SEPARATE CLAIM FORM FOR EACH PLAN A COPY OF THIS DOCUMENT AND ALL RECEIPTS FOR YOUR SPONSOR AND PLAN MEMBER INFORMATIONPlan Sponsor:Full Company NamePlan Member://Last NameFirst NameDate of Birth (YY/MM/DD)Plan Member Address:Apartment/Number/StreetCityProvi ncePostal CodePLAN SPONSOR PAYMENT CALCULATIONPremium Tax: :ON:13%NB:15%NL:15%NS:15%PE:14% :ON:8%QC:9%Total claim amount:(total of all medical and dental receipts being submitted)A$Administration fee:Box A x 5% (Minimum $ ; Maximum $ )B$Total claim amount and administration fee:Box A + Box BC$Premium Tax:Box C x Premium Tax rate based on Plan Member s province of residenceD$Harmonized Sales Tax ( #103610648RT0001):Box B x rate for harmonized provincesE$Goods and Services Tax ( #103610648RT0001):Box B x 5% for non-harmonized provincesF$Provincial Sales Tax ( #103610648TR0002):Box A x rate for Plan Members resident in Ontario and QuebecG$Total amount payable to MDM:(total of Boxes C to G)H$ Revenue Canada has indicated that a personal cost plus plan for the owner/proprietor (and dependents) only may not qualify as a PrivateHealth Services Plan, therefore any contribution or premium and administration charges the owner/proprietor pays the Insurance Companyto reimburse eligible medical and/or dental claims may not be considered an eligible tax deduction according to Revenue Canada. PAYMENT INSTRUCTIONSPlease send this claim form, all supporting documents ( , original receipts, benefit statements, etc.), and your cheque made payable to MDM ASO Plan for the total amount payable to MDM, shown above in Box H, to: Plan Administrator, ASOMDM Insurance Services Box 970, Guelph, Ontario N1H 6N1NOTE:In order to be eligible for payment, all receiptsmust be submitted within 24 months of thedate that the expense was SPONSOR AUTHORIZATIONClaim cheque made payable to: Plan Member, or Claim cheque sent to: Plan Member s address, or other address:Authorized Signature of Plan SponsorPlease print nameDate (YYYY/MM/DD)Before implementing a Cost Plus program, we strongly encourage you to consult with your professional tax advisor. You want tobe sure that you are eligible to implement a Cost Plus program and before any expenses are submitted for reimbursement, you needto be sure that these expenses are eligible. For a complete list of eligible medical expenses (Income Folio Medical ExpenseTax Deduction), you can visit Revenue Canada's Web site at or by calling : 2017/5/1

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