Reimbursement Request

Cost Plus or Healthcare Spending Account Only

To submit a claim to your group benefits plan,
please contact your employer in order to send the claim to the right place.

Plan member information

Information on the request

Do the costs incurred result from a work accident or an occupational disease? ouinon

Do the costs incurred result from a road accident? ouinon

Please contact the CNESST (if work accident or occupational disease) or the SAAQ (if road accident) to know the admissibility of these claims with the organisation.
If the costs incurred are not admissible to a refund by your group benefits plan, please include a copy of your invoices.
If the costs incurred are admissible to a refund by your group benefits plan, please include the benefit statement that demonstrates the non-refunded portion of your original claim.
If the costs incurred are for dental care, please include the standard dental claim form completed by your dentist.

Claim details

Complete name of the claimant	Relation	Date of birth	Submitted amount







		Total

I hereby confirm that the submitted costs were incurred by either my dependants or myself, exclusively to the use of the specified claimant, and that the above information are correct.

Pre-authorized Registration

Electronic copy of voided check

Transmission of receipts

Attach a copy of all your receipts ^*Required

With the voided check, I authorize SAGE Assurances et rentes collectives to make deposits in my bank account.