BENEFIT ENTITLEMENT REVIEW To fill out the form, choose one of the two options below. You can fill out the form online, or download the PDF version and fax or email it to us. BENEFIT ENTITLEMENT REVIEW BENEFIT ENTITLEMENT REVIEW Step 1 of 3 33% CONFIDENTIAL APPLICATIONMEMBER’S NAME* First Name Last Name DATE OF APPLICATION* Date Format: DD slash MM slash YYYY DD/MM/YYYYCERTIFICATE No.*123 4567 896 0ADDRESS* Street Address City Postal Code PHONE NUMBER*(000) 000-0000EMAIL ADDRESS* Enter Email Confirm Email CONFIDENTIAL APPLICATION Have you spoken with a Claims Specialist at Johnson Inc?*YesNoPlease provide the name of the person*Name of the personDate of the call* Date Format: DD slash MM slash YYYY DD/MM/YYYYIf you have not yet spoken with a Claims Specialist regarding your claim, please do so prior to submitting your application. They may be reached, toll-free, at 1-800-442-4428 or 506-454-4654 (Fredericton area).Which NBTF Group Insurance Plan option does your claim originate from?* Health and Prescription Drugs Dental Travel Other Please explain briefly, in the space provided, the nature of your claim, why it was not reimbursed, and the reasons for appealing the decision:* CONFIDENTIAL APPLICATIONPlease attach all documents relevant to your Benefit entitlement review (Claims requests, receipts, correspondance with Johnson, doctor's letter, etc.) Completed Claims Form Drop files here or Receipts Drop files here or Copy of any correspondence from Johnson Inc. concerning this claim Drop files here or Authorization* I consent to the collection, use and disclosure of all information required by NBTF Group Insurance Plan, Johnson Inc., Manulife Financial and/or Allianz Global Assistance to process this application. This information will be held in strict confidence.