Reimbursement Request

Cost Plus or Healthcare Spending account

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

Pre-authorized Registration

Electronic copy of voided check

Transmission of receipts

Attach a copy of all your receipts

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