The Claim Form - For Ontario Only
*required fields Note:please use your TAB key to navigate.
Company Name * Employee Name *
ID# (if applic.) E-mail *
Employee Address * City *
Province * Postal Code *
Please Send My Payment To direct deposit company address above address *
  **Note: For direct deposit, current direct deposit information must be on file with the trust or attach a completed direct deposit form.
Only Official Receipts must accompany this form. Receipts must clearly indicate
the date of service, the amount of purchase, and the patient name.
Date of Service   Type of Service  
Month Day Year Employee Name / Dependant Name Medical / Dental / Vision Amount Paid


Print this completed form, attach ALL OFFICIAL RECEIPTS
and send to:

AVP Health & Welfare Trust

222, 855 - 42 Avenue SE
Calgary AB T2G 1Y8
Total Claims
Admin Fee 10% (of claims)
Sub-Total (claims + admin)
HST 13% (of admin fee)
PST 8% (of claims)
Premium Tax 2% (of claims + admin)
Total Expense

FYI:
Claims = Employee's out-of-pocket costs
Expense = Employer's Amount payable (to trust)
Questions?

Call: 403.214.3213 or 888.214.3211
Toll Free Fax: 866.213.5514
E-mail: info@bizflex.ca
www.bizflex.ca