Cost Efficient Benefit Plan
(Div. of Paloma Ventures Ltd.)
Mailing Address: 234, 5149 Country Hills Blvd. NW, Ste. 513, Calgary, Alberta T3A 5K8
Phone: 403-282-3776 Fax: 403-202-5046 Toll Free: 1-800-651-3776
Office Location: 216, 3907 - 3A Street NE, Calgary, AB (Do not mail to this address)
Website: www.costplus.ca Email: info@costplus.ca
Remittance Form
* Fields with red asterisks are required.
Date: * (mmm dd, yyyy) ------------------------
Business Name: * ------------------------
Employee Name: * ------------------------
Phone: ------------------------
Your Email Address: * ------------------------
I have a new address: ------------------------
City: Province:*
Postal Code:
Claims submitted via this form constitutes consent to continue to contact you/your business by email.
List Current Claims Note: Eligible receipts must be submitted to support your claim
Description of Expenses (65 characters)Amount


Miscellaneous notes (500 characters):


Total Current Claim:
Administration Fee (5%):
GST/HST:
Total Payable: Make cheques payable to Cost Efficient Benefit Plan
  Attach Receipts     (max files=5; max size=8MB (8000kb))
Click browse to attach a file. Up to five files can be attached. Each file can be up to 8MB in size.
Reimbursement payable to: (employee name or business name) *
   
If you are mailing in your claim, return this completed form, together with all receipts and your payment to:  
Cost Efficient Benefit Plan
234, 5149 Country Hills Blvd. NW, Ste. 513 Calgary, Alberta T3A 5K8