Submission date: Apr.

8, 2024

ANDJELKO GIGOVIC
154 WEST GROVE POINT SW
CALGARY, Alberta
T3H 1V3

Summary - Online claim submission

Plan member: ALEKSANDRA GIGOVIC
Plan number: 52263
Member ID (or certificate number): E000004171
Confirmation number: 080424-162063-00

Claim Details - Massage therapist

Length of visit Amount
reimbursed by Claim
Service date Service type Visit type Total charge
Hours Minutes other benefit amount
plan
02 MAR Subsequent Provider's
0 30 $68.25 $47.77 $20.48
2024 visit office
Total
$68.25 - $47.77 = $20.48
charge:

1
 Submission date: Apr. 8, 2024

ANDJELKO GIGOVIC
154 WEST GROVE POINT SW
CALGARY, Alberta
T3H 1V3

Summary - Online claim submission

Continued from previous page

Provider: SAMANTHA GREIG MOHNS

Patient: ALEKSANDRA GIGOVIC
Number of claim documents added: 1
Is ALEKSANDRA covered for this claim type (Massage therapist) under
another benefits plan? Let’s coordinate your benefits between the 2 plans. Yes
Did you submit your claim to the other benefits plan yet? Yes
Is this claim related to an accident or injury? No
Did ALEKSANDRA get a doctor’s referral or prescription for this expense? No

2
 Submission date: Apr. 8, 2024

ANDJELKO GIGOVIC
154 WEST GROVE POINT SW
CALGARY, Alberta
T3H 1V3

Summary - Online claim submission

Continued from previous page

I certify that the information provided is true, correct and complete to the best of my knowledge. I certify that all
goods and services being claimed have been received by me, my spouse and/or my dependants.

The submission of fraudulent claims is a criminal offence. Canada Life takes the submission of
fraudulent claims seriously. Suspected fraudulent claims may be reported to your employer or plan
sponsor and to the appropriate law enforcement agency.

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disclosure of personal information as set out in the Privacy guidelines. This includes the administration of my
products or services and to help us analyze and optimize customer service and business processes. Personal
information may be disclosed to service providers and others referred to in the Privacy guidelines, where
required to administer products or services.

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Visit us at our personalized secure Winnipeg Benefit Payments 1-800-957-9777

service site for plan members at P.O. Box 3050 Station Main
canadalife.com Winnipeg, Manitoba
R3C 0E6