Request for Health Spending Account Reimbursement
									Please submit a separate claim form for each member.
					MEDICINE HAT OILMEN'S ASSOCIATION
Name of Employer								Group Policy Number
I, the undersigned, hereby request the expenses outlined below be reimbursed on an administrative services only basis.
Name of Employee								GMS Identification Number
Name of Claimant				Type of Service				Reimbursement Amount
								$
								$
								$
								$
								$
								$
								$
				Total Charges of Claims			A	$
				Administration Fee (10% of A)			B	$
				GST (7% of B)			C	$
				Total of A, B & C			D	$
A cheque in the amount of $ ____________, payable to GMS Insurance Inc. is enclosed with this form, together with all paid
receipts pertaining to the reimbursements being claimed.
I understand that GMS Insurance Inc. will issue a cheque payable to the employee for the total amount to be reimbursed.
Dated this _____ day of ___________________, 200__.
						Signature of Authorized Official