LWFT NN 209 15215

Statement date: December 27, 2023

Your plan number: 0087090
000007474 Your certificate number: 7198333
HEIDI GIRARD
Group name: THE TORONTO-DOMINION
144 RENISON AVE
BANK
PORCUPINE ON P0N 1K0
Benefit paid to: HEIDI GIRARD
Payment issued

Questions?

claim statement
Internet: www.manulife.ca/planmember

Your health Call: 1-866-646-1070

Write: Group Health Claims
PO Box 1653
Waterloo, ON N2J 4W1

Summary of your claim

Amount Benefit Any unpaid portion of this claim may be
Description submitted ($) paid ($) eligible for reimbursement from your Health
TOTAL FOR SYDNEY 300.00 300.00
Spending Account; use the Health Spending
Account claim form to submit these
CLAIM TOTAL $300.00 $300.00 expenses.
Amount of direct deposit: $300.00

Details of your claim

SYDNEY (child)
Amount Amount Percent Benefit
Description submitted ($) eligible ($) paid paid ($)

Service date: December 12, 2023

Service: Social Worker - 1 visit 150.00 150.00 100% 150.00

Service date: December 19, 2023

Service: Social Worker - 1 visit 150.00 150.00 100% 150.00

TOTAL FOR SYDNEY $300.00 $300.00 $300.00

Important messages
Please ensure all claim forms are signed when submitting for payment.

Continued on back
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 Statement date: December 27, 2023
Your plan number: 0087090
Your certificate number: 7198333
Insured: HEIDI GIRARD

Important messages continued

Please keep this document for income tax purposes, or if coordinating benefits with another plan. This document is sufficient
for income tax purposes. If you need a replacement copy, we charge a fee.

Respecting your privacy has always been important to us. We invite you to review our privacy policy online at
www.manulife.ca, scroll to the bottom of the page and click on 'privacy policy', or call us at 1-800-268-6195.

Key terms
Following are some explanations of key terms used in this claim statement.
Amount submitted - The amount you were charged for a product or service.
Amount eligible - The portion of the amount submitted that is eligible for whole or partial reimbursement by your plan.
Percent paid (coinsurance) - The percentage of the amount eligible that your plan covers, sometimes referred to as
coinsurance. For example, if your plan covers 80% of the amount eligible, then you will not be reimbursed for the other 20%.

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