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Dental Claim Form

To submit a manual claim, complete an insurance Dental Claim Form, attach the original receipts and documents, and mail to the insurer. Remember to keep a copy of all original documents for your records.

IMPORTANT! Eligible students MUST activate their coverage via the Personal Information Form in order to submit claims via the Dental Claim Form.

The following information is required on the claim form:

Plan Number: 330756
Division Number: Not Applicable Leave Blank
Plan Name: Students' Association of Mount Royal University (SAMRU)
Employee Identification Number: Your Student ID
Employee Name: Your Name
Address: Your Current Mailing Address

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