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How to submit Proof of Coverage

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					How to submit Proof of Coverage

        InformatIon
        reQuIred                                   Proof of Coverage examPles
	 Your document must clearly
  indicate your coverage for
  extended health and/or dental care,               Web Image example
  the insurance company name, and
  the policy number. Your proof of                                                                     name of
                                                   benefIts summary from a ComPany’s WebsIte
                                                                                                      InsuranCe
  coverage should relate to the portion
                                                                                                      ComPany/
  of the plan that you want to opt out of.                                                               logo
                                                   Date: 00/00/0000               your
                                                                                  InsuranCe
                                                   Participant: your full name    ComPany              name of
                                                                                                      emPloyer/
        aCCePtable                                 Policy number: 00000000        your                  logo
        doCuments                                                                 ComPany
                                                                                                       HealtH
  	An	image of a summary of                                                                            and/or
                                                   Coverage Summary: Health and/or dental Coverage     dental
   benefits from an insurance
                                                                                                      Coverage
   company website

  	A	copy of a certificate	or	card	               your         your
                                                  name        PolICy
  	A	letter from the plan sponsor                            number
   (usually the employer) or the
   insurance company                                                             or

  	Aboriginal students who receive
   benefits from Health Canada may                                     Card example
   provide a copy of their status card.
                                              name of        your                                       HealtH
                                             InsuranCe       InsuranCe                Health and/or     and/or
                                              ComPany        ComPany                    dental Plan     dental
                                                                                                       Coverage
       It’s easy to                             your
       submIt your                             PolICy        Policy 0000000
                                              number
       doCuments
                                             your name       your full name           date of birth
ElEctronic	documEnts
(from a company’s website)
                                                                                 or
1		You can use the print screen
  button to	capture	an	image
  of your screen                                                      letter example
2		copy,	paste, and save it in a
                                                             your ComPany letterHead
  Word	document, as a PdF,
  or an	image	file, such as
                                                             the date
  a tiff, gif, jpeg, or png.
                                             your name       Re: your full name

PrintEd	documEnts                                            To Whom it May Concern:
                                                             This letter serves as confirmation         HealtH
1		scan	your letter/card                                                                                and/or
                                                             that your name has extended
  OR	take	a	picture	with a                                   health and/or dental coverage
                                                                                                        dental
  digital camera or smart phone.              name of                                                  Coverage
                                             emPloyer        as an employee of the place where
                                                             you work. Our benefits provider is the
2		Save it in	PdF	format,	Word,                              name of your insurance company            name of
  or as an	image	file.                          your         and our policy number is your            InsuranCe
                                               PolICy        insurance policy number.                  ComPany
                                              number
                                                             Yours truly,

                                                             signature of benefits administrator

                                               ContaCt       your benefits administrator
                                             InformatIon     their department
                                                             (Phone number + extension)

				
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posted:6/17/2012
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