Claim Form
Submit this claim form and original receipts to your employer
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PROMEDENT ADMINISTRATION INC. Head Office, 2066 Qualicum Drive, 1st Floor, Vancouver, BC, V5P 2M2 Tel 604.327.2022 Fax 604.324.1762 www.promedent.ca (hereinafter called "Promedent") |
| Employer Legal Business Name: ________________________________________________________ |
| Business Address: ___________________________________________________________________ |
| City: _____________________________________ Province: ______________ Postal: ____________ |
| Employee Name: ____________________________________________________________________ |
| Address: ___________________________________________________________________________ |
| City: _____________________________________ Province: ______________ Postal: ____________ |
| Payment Date |
Patient Name |
Relationship | Payment made to |
Description | Payment Amount |
Claim Amount |
| TOTAL CLAIM AMOUNT TO BE REIMBURSED | ||||||
| Description | With Electronic Funds Transfer ("EFT") |
Without Electronic Funds Transfer ("EFT") |
| Total Claim Amount to be reimbursed | ||
| Administration Fee with GST (GST# 89758 4314 RT0001) | ||
| Administration Fee with HST (HST# 89758 4314) | ||
| Payment to Promedent Administration Inc. |
The employee indicated above, will be issued a reimbursement cheque or EFT. Please allow up to 30 days for processing. |
I agree to hold harmless Promedent Administration Inc., its directors and employees, who accept no responsibility or liability for any damages, penalties or assessments of income tax that may arise from this claim. |
Signature of employee: ________________________________ Date: _____________________________ |
As an authorized representative of the above Employer, I request that the expenses listed above be reimbursed on a cost-plus basis. I confirm that such expenses qualify as medical expenses under Section 118.2(2) of the Income Tax Act and are within the claimant's annual reimbursement limit. |
Signature of employer: __________________________________________ Date: _____________________________ |
| Employee instructions: | Submit this claim form and original receipts to your employer. |
| Employer instructions: | Retain copies for audit purposes. Once you have electronically approved this claim, you will not be required to submit any written documents to Promedent if you are using EFT. If you are manually submitting this form, you must send a copy of this form with a cheque to Promedent Administration Inc., Head Office, 2066 Qualicum Drive, 1st Floor, Vancouver, BC V5P 2M2. |
| If you are manually submitting a cheque, you must submit a signed copy of this claim form with your cheque to Promedent, 2066 Qualicum Drive, Vancouver, BC V5P 2M2. | |