Cost Efficient Benefit Plan (Div. of Paloma Ventures Ltd.) 234, 5149 Country Hills Blvd. NW, Ste. 513 Calgary, Alberta T3A 5K8 Tel: 403-282-3776 Fax: 403-202-5046 Toll Free: 1-800-651-3776 London, ON Tel: 519-637-2200 Toll Free: 1-866-965-2201 Website: www.costplus.ca Remittance Form
	* Date: mm/dd/yyyy
Firm Name: *
Employee Name: *
Your email address:
List Current Claims Note: All original receipts must be submitted to support your claim Use tab key to progress from each cell
Description of Expenses Amount  1   Total Current Claims *  2   Administration Fee (click on one that applies to your company)    8%   5%  3    GST (Calculated on administration fee only) 13%   12%   5%  4   Total Payable
Make cheque payable to Cost Efficient Benefit Plan Please make cheque payable to Employee (name)                         OR Please make cheque payable to Firm
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
A Private Health Services Plan (PHSP)