HealthPlus from CAPCORP Financial

HealthPlus Invoice

Company Name:

Date Submitted

Feedback on HealthPlus:

Company Address:

Phone #:

Email Address:

Fiscal year-end:

(day/month)

CAPCORP Advisor:

(if applicable)

Full Employee
Name

Full Dependant
Name

(if applicable)

Type of Claim
(Health or Dental)

Reimbursement
Percentage

Expense
Amount

Claim
Amount

Total Claim Amount:

Administration Fee:

10% of Item A

H.S.T (Reg. # 89263 8503 RT0001)

13% of Item B

Premium Tax

2% of Items A+B

P.S.T. (Reg. # 89263 8503 TR0001)

8% of Item A

TOTAL AMOUNT REMITTED:

A+B+C+D+E =

Prepared by:

Name:
Signature:

Office Use:

PRIVACY AND CONFIDENTIALITY STATEMENT
At CAPCORP, your privacy is important to us. We have established a confidential file in which we retain all material relative to your participation in the CAPCORP Multi-employer Health and Welfare Trust. The confidential file is kept in the offices of CAPCORP Planning (2003) Inc. Access to this file is limited to those persons authorized by CAPCORP Planning (2003) Inc. who require the information to perform their duties relative to the CAPCORP Multi-employer Health and Welfare Trust or relative to the other business agreements between your firm and CAPCORP.

Mail completed Invoice with supporting documentation and payment to:

CAPCORP
ATTN: HealthPlus Claims
1050 Morrison Dr., 3rd Floor
Ottawa, ON K2H 8K7