File a claim

If you do not have all information on hand, please indicate this in the “Comments” section at the end of this form.

Your claim

Your claim will be processed based on the type of insurance you have.

Identify which of the following apply to your situation:

Sick leave (disability)
Accidental fracture
Loss of use of a limb or loss of sight
Hospitalization or home health care expenses
Paramedical costs resulting from an accident

Are you filing this claim for yourself?
You will receive an acknowledgment of receipt of your claim.

You will receive an acknowledgment of receipt of your claim.

Did you know that using a valid email address speeds up the processing of your claim?



Can you provide the insurance policy number(s) related to this claim? This information will help us to speed up the processing of your claim.

File a claim

If you do not have all information on hand, please indicate this in the “Comments” section at the end of this form.

About you About

Date of birth
About your sick leave (disability) About ’s sick leave (disability)
Sick leave start date
Maximum of 5,000 characters 0 character(s)
Is the disability the result of an accident?
Date of the accident

Have you returned to work? Has the insured returned to work?
During your disability period, did you do any work for which you received compensation (light duties, temporary assignment, etc.)? During the disability period, did the insured do any work for which he received compensation (light duties, temporary assignment, etc.)? During your disability period, did you do any work for which you received compensation (light duties, temporary assignment, etc.)? During the disability period, did the insured do any work for which he received compensation (light duties, temporary assignment, etc.)?
Start date
End date (if applicable)

Date of return to work
Anticipated date of return to full-time work (if known)

Were you hospitalized? Was the insured hospitalized?
Date admitted
Date released (if applicable)
About your accidental fracture About ’s accidental fracture
Date of the incident causing the fracture
Maximum of 5,000 characters 0 character(s)
Is the fracture caused by a motorized vehicle accident?

Were you driving at the time of the accident? Was the insured driving at the time of the accident?


Check all that apply:
About your loss-of-use of a limb or loss of sight About ’s loss-of-use of a limb or loss of sight
Is the loss-of-use of a limb or loss of sight the reason for your disability? Is the loss-of-use of a limb or loss of sight the reason for the insured's disability?
Date of the incident causing the loss-of-use of a limb or loss of sight
Maximum of 5,000 characters 0 character(s)
Date of the incident causing the loss-of-use of a limb or loss of sight
Maximum of 5,000 characters 0 character(s)
Is the loss-of-use of a limb or loss of sight caused by a motorized vehicle accident?
Were you driving at the time of the accident? Was the insured driving at the time of the accident?
Was a specialist consulted?
Supporting document and comments
No supporting documents are required at this time. We will contact the policyowner as needed.

Providing a copy of this document will help speed up the processing of your claim.

Providing a copy of these documents will help speed up the processing of your claim.

Providing a copy of this document will help speed up the processing of your claim.

  • Hospitalization summary indicating the duration and reason
  • Invoices for claimed home health care expenses (if applicable)
  • Radiology report
  • Doctor’s note indicating the date, cause and nature of the loss of use
  • Invoices for claimed paramedical costs
  • Medical document indicating the date, cause and diagnosis
  • Statement of reimbursement from another insurer (if applicable)

Do you have these documents? Send them now.
Is a document missing? Request it as soon as possible. Doing so will help you avoid slowing down the claim review process. Do you have this documents? Send it now.
Is the document missing? Request it as soon as possible. Doing so will help you avoid slowing down the claim review process.

Maximum of 5,000 characters 0 character(s)

Information summary

If you do not have all information on hand, please indicate this in the “Comments” section at the end of this form.

Your claim

About you About

About your sick leave (disability) About ’s sick leave (disability)

About your accidental fracture About ’s accidental fracture

About your loss-of-use of a limb or loss of sight About ’s loss-of-use of a limb or loss of sight

Supporting document and comments

Declaration

Information summary

Your claim

About you About

About your sick leave (disability) About ’s sick leave (disability)

About your accidental fracture About ’s accidental fracture

About your loss-of-use of a limb or loss of sight About ’s loss-of-use of a limb or loss of sight

Supporting document and comments

Need help?

Do you have questions about your claim?