I certify that the statements above are complete and true and that all attached receipts represent no duplication of charges previously submitted.

I authorize:

Physicians, hospitals and/or any other service providers to exchange full information and records deemed relevant to this claim with Pacific Rim Administration Services (PRAS), its agents, representatives and/or its consultants and/or the insurer(s), their representatives, agents and/or consultants for the purposes of assessing adjudicating and/or managing this claim. PRAS to exchange information with the insurer(s),and/or its agents or representatives, policyholder/plan administrator and agent of record with regard to any group statistical information that may include information concerning claims paid on my behalf or on behalf of my eligible dependents (other than specific details relating to the medical condition(s) for the purpose of negotiating group renewals, premiums/deposits and benefits management. I understand all claims made under this Group Plan are submitted through the plan member. PRAS may exchange information about these claims with the plan member or any person acting on his or her behalf (as deemed necessary) for the purpose of confirming eligibility and assessing and managing the claim.

I agree to retain these original receipts for seven (7) years as per CRA requirements.