THE MARITIME LIFE ASSURANCE COMPANY EMPLOYER MUST COMPLETE THIS

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THE MARITIME LIFE ASSURANCE COMPANY EMPLOYER MUST COMPLETE THIS Powered By Docstoc
					 THE MARITIME LIFE ASSURANCE COMPANY                                                         VISION CARE
                                                                                             STATEMENT OF CLAIM
EMPLOYER MUST COMPLETE THIS SECTION
 Employer                       Employer Location (City & Province)                                   Group No.              Account

 Date Employee Eligible                        Date Dependent Eligible                               Date Employee Terminated

 Date                                        Signature of Employers Representative                             Product Set I.D.

      EMPLOYEE (Please Print or Type) YOUR CLAIM CANNOT BE PROCESSED UNTIL ALL QUESTIONS HAVE BEEN ANSWERED IN FULL
 Employee’s Name                Employee I.D.                          Date of Birth                                         Sex
                                                                       Day           Month            Year
 Employees Address

 NO. & Address                           City                                       Province                                 Postal Code
 Dependent’s Name                      Relationship                    Date of Birth                                   Sex

                                                                 Day       Month       Year
Do you have another plan that provides Health or Dental benefits for you or your dependents?         □ NO □ YES
 □ Health Only         □ Dental Only □ Both
If yes, is the other coverage provided through: □ Maritime Life □ Another Insurer If Maritime Life, Indicate Policy Number:
If claim is for a dependent child, please indicate spouse’s date of birth:
If claim is for child, indicate: □ Fulltime Student, date enrolled:             date completed:            □ Handicapped
Is treatment a result of an occupational injury, or otherwise related to employment? □ No □ Yes
TO BE COMPLETED BY SUPPLIER
             Patients Name
 Prescribed by:                      □ Ophthalmologist                □ Optometrist          Is this a change of prescription? □ Yes □ No

                  Sphere          Cylinder      Axis         Prism      Base          P.D.           Seg             Frame
                                                                                                     Height          and Colour
                                                                                               Far                         Eye             DBL              Temple
  R                                                                                                                        Size
                                                                                               Near
  L
                       R            Tint (Specify Colour Type of Bifocal                       Type of Trifocal               Manufacturer or Supplier
  A                                 and No.)
  D                    L
  D                                 1           2
  □ Plastic    □ Heat Hardened □ Chemically Hardened                                           Breakdown of extra charges:
  For additional information re: complications, etc.                                           Miscellaneous:
                                                                                               1.                                           $
                                                                                               2.                                           $
                                                                                               3.                                           $
                                                                                               4.                                           $
                                                                                                                      Charges:
  SUPPLIER                        Day          Month        Year                               Frame:
                                           Date Ordered
                                                                                               Lenses:
  Name
  Address                                                                                      Contacts:
  City/Town                          Prov.
  Postal Code                        Telephone:                                                Fee:
  □ Optometrist                      □ Optician                                                Misc 1:
  Signature of Supplier:                                                                       Misc 2:

                                                                                               Total:

  I understand that the charges listed in this claim may not be covered by or may exceed my agreement         I hereby assign my benefits payable from this claim to
  benefits. I understand that I am financially responsible to my supplier for the cost of those services.     the supplier named below and authorize payment
  Authorization: On behalf of myself and my eligible dependents, I authorize my employer and my               directly to him/her. Do not sign below if you do not
  group benefit provider, The Maritime Life Assurance Company and any of its affiliates or reinsurers to      wish the Insurer/Plan Administrator to pay the supplier
  exchange the personal information contained on this form or any other benefit related personal              directly.
  information contained in their files now or in the future respecting me or any of my eligible
  dependents. I give my consent on the understanding that the information will be used solely for
  purposes of administration and management of my group benefit plan. This consent shall continue
  so long as I and my dependents are covered by, or are claiming benefits under the present group
  contract, or any modification, renewal or reinstatement thereof.


  Date Signed (Day/Month/Year)                  Signature of Employee (payment directly to employee)           Signature of Employee (payment directly to supplier)



              Date                                         Signature of Spouse if claim is to be coordinated with another Maritime Life Plan