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

    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.