Remittance Form

*Fields marked with asterisks are required.

Employee and company details Your company's name*: In which province is your company based?* Company account number (optional): Employee name: (Name of person enrolled in the plan, rather than dependants.)* Reimbursement payable to: (employee name or business name)*

Telephone*: E-mail address*: (A copy of this form will be sent to this e-mail address.)

Optional:

If you have a new address, enter it here: City: Province: Postal code:

This is the company's address

This is the employee's address

This is the address for the company and employee.

Claims submitted via this form constitutes consent to continue to contact you/your business by email.

List expenses

Please ensure that the amounts you have entered consist of numbers only, with no currency symbols or commas.

Claim description:

Amount:

Add another item

Miscellaneous notes:

Amounts should consist of numbers only, with no currency symbols or commas. Press the below 'Recalculate totals' button if you have made any corrections.

Calculate totals

Total Current Claim:

5% Administration Fee:

GST/HST:

Total Payable:

Payment to Cost Efficient Benefit Plan can be made by your company through online bill payment, cheque or e-transfer. (Instructions will be included in the approval e-mail.) If paying by cheque, make it payable to Cost Efficient Benefit Plan.

Receipts

Attach receipts here: (Multiple files can be uploaded per line.)

Add another file

If you are mailing in your receipts, return this completed form, which will be e-mailed to you, together with all receipts and your payment to:

Cost Efficient Benefit Plan
234, 5149 Country Hills Blvd. NW, Ste. 513 Calgary, Alberta T3A 5K8

Please ensure all fields marked with an asterisk have been filled in.

This form will be e-mailed to you. If you would like a printed copy of the submitted form, we recommend printing the e-mail.

After we have reviewed your receipts, your company will receive another e-mail confirming the total owing.

This form has not yet been submitted.
If you require a paper copy of the submitted form, simply print the completed version which will be e-mailed to you upon clicking the Submit button.

Cost Efficient Benefit Plan
Tel: 403-282-3776 | Toll-free: 1-800-651-3776
E-mail: info@costplus.ca | Website: www.costplus.ca