Forms

REMINDER: any eligible 2019 expenses must be submitted to their appropriate offices by JUNE 30, 2020 no exceptions!!

MEDICAL EXPENSE CLAIM FORM (Click here)
Print, complete and mail WITH original receipts to Coughlin & Associates: PO BOX 764, Winnipeg, MB, R3C 2L4.

DENTAL CLAIM FORM (Click here)
Print, complete and mail WITH original receipts to Coughlin & Associates: PO BOX 764, Winnipeg, MB, R3C 2L4.

VISIONCARE CLAIM FORM (Click here)
Print, complete and mail WITH original receipts to the Welfare Office: #203-1658 Fosters Way, Delta, BC, V3M 6S6.

SPECIAL SENIOR MEMBER SSM CLAIM FORM (Click here)
Print, complete and mail WITH original receipts to the Welfare Office: #203-1658 Fosters Way, Delta, BC, V3M 6S6.
$35/calendar year maximum for prostate testing + $800 (before June 30, 2019) increased to $900 July 01, 2019/calendar year maximum.

PRE-AUTHORIZED DEPOSIT FORM – Plumbers Local 170 (for MSP, Visioncare & Special Senior Member claims to be directly deposited)
Print, complete and return to the Welfare Office: #203-1658 Fosters Way, Delta, BC, V3M 6S6.

MEDICAL SERVICES PLAN (BC MSP) REIMBURSEMENT GUIDELINES:

The plan does not pay MSP premiums for or on behalf of covered members;
but will reimburse to: Hour Bank insured members and eligible disabled members.
A covered individual will not receive reimbursement from the plan in respect of MSP premiums, until the administrator is satisfied that the covered individual actually paid the MSP premiums and the covered individual completes and delivers to the administrator such forms and documents as the administrator may require from time to time.  For detailed information regarding MSP reimbursements, please refer to the Member Handbook: Medical Services Plan (MSP) section.

For a covered Hour Bank member to be reimbursed MSP premiums, the Administrator requires along with proof of payment, the following:
A copy of the whole (top and bottom) MSP billing in the member’s name clearly indicating the month and dependants they are claiming.
If the member has MSP automatic withdrawal, the bank statement must clearly provide the member’s name.

The following are acceptable proof of payment:
~ Bank Statement;
~ Bank stamped MSP billing notice; and/or
~ copy of online payment confirmation.
All MSP reimbursements submitted must be accompanied by proof of payment.

Reminder:  the Plumbers Local 170 Welfare Office must receive your claim by JUNE 30 of the calendar year following the year.
Example: 2019 MSP premiums must be in by June 30, 2020 for reimbursement.