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Benefit Claim Inquiry Request

Form Purpose – To be completed if you disagree with the claim payment you received from Sun Life Insurance regarding a health or dental benefit claim.

When complete – Please forward to Natasha Cowan, Pension & Benefit Administrator, Payroll Dept. | |

|Name |

|Department |Union |

|Phone number |

|Date of Claim: |Type of Claim: |

| |( Extended Health ( Dental |

|Have you contacted Sun Life regarding this matter? ( No ( Yes |

|If yes, please provide details of the call, including name of the Adjudicator spoke to. |

|Reason For Denial |

|PLEASE ATTACH COPY OF THE EXPLANATION OF BENEFITS YOU RECEIVED FROM SUN LIFE |

|Resolution (for administrative purposes only) |

| |

| |

| |

| |

|( Adjudication Error ( Incomplete Information Provided ( |

|Coordination of Benefits Issue ( Dependent Status not updated ( Other |

|___________________________ |

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