Health, dental and disability claim forms
Note: All claim forms can be opened with the application Adobe Reader. If you don’t have Adobe Reader, you can download it for free by clicking here:
Important
Claims filed for health care costs or disability benefits must be sent to the insurer within a certain period of time. This information is available in the Claimant's Statement. If the claim is not sent within the time specified, it could be refused by the insurer.
Health insurance
Extended health care benefits
This form is used for health care benefits, such as medical or paramedical expenses, drugs and vision care. Complete this form online, save it, print and sign it, and mail it to us along with your original receipts.
Important: Claims must be submitted no later than 12 months after expenses are incurred.
Hospital allowance or daily indemnity
The Claimant's Statement is provided with the Hospitalization Certificate. Both are required for any claim under one of the following benefits: hospitalization, hospital allowance or daily indemnity. They may also be used to claim ambulance transportation expenses.
Important: The Hospitalization Certificate must be completed by an authorized agent.
Dental care
This form is used for dental claims. In most cases, your dentist will be able to submit claims automatically through an electronic data interchange (EDI) system.
If your dentist has EDI, you'll just need to provide your policy and ID numbers. Your dentist will electronically submit your claim to us, and we'll mail you or your dentist a reimbursement cheque for any eligible expenses.
If your dentist does not have EDI, please submit the completed and signed dental claim form provided to you by your dentist.
Accidental fracture
The Claimant's Statement must be provided with the Attending Physician’s Statement. Both are required for any claims related to an accidental fracture.
Critical illness
The Claimant's Statement, Attending Physician’s Statement and Medical Certificate are required for any claims filed for medical care costs related to a critical illness covered by the contract.
Important: The Medical Certificate must be completed by an authorized agent if the insured received out-patient treatments or home health care.
Accidental loss of use or dismemberment
The Claimant's Statement and Attending Physician’s Statement are required for any claims related to accidental loss of use or accidental dismemberment.