Follow the steps to fill out the form accurately and efficiently.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by filling in the employer or store number in the designated field. Make sure this information is accurate as it is essential for processing your claim.
3. Enter your employee number in the corresponding field below the employer/store number.
4. Provide your full name as the member, ensuring correct spelling as it appears on official documents.
5. Input your social insurance number (ID) following the prompt, as it will be used for verification purposes.
6. Include your date of birth in the specified format, selecting the month, day, and year separately.
7. Fill in your complete address, including house number, street, city, province, and postal code.
8. Indicate your gender in the relevant section.
9. Answer the question regarding any other coverage that may pay for this claim by circling 'Yes' or 'No.' If applicable, name the employer and the insurance company associated with this coverage.
10. For each claim, enter the date in the mm/dd/yyyy format, followed by the type of expense (vision or drug name) and the name of the pharmacy or vision care provider. Include the total charge for each item.
11. If you need more space for items, attach a separate sheet and ensure it includes all the required information.
12. Calculate the total of all charges and enter it in the designated section at the bottom of the form.
13. Read and complete the certification and consent section carefully. Your signature and the date are required to confirm the accuracy of the information provided and authorize the use of your social insurance number.
14. Provide your telephone number for contact purposes.
15. Once all sections are completed, save any changes you have made, and ensure to download, print, or share the completed form as needed.

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