If ‘yes’ please confirm your personal Global Medical Assistance Identification Number.
•
Employee’s Name ID# Plan Number
Plan Name Total Amount being Claimed $
Plan Administrator Signature Date
Name Relationship to employee
Address
Parent/Guardian
Child’s Current Address
Claimant’s Signature
Date
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
Accidental Death, Dismemberment &
Specific Loss Supplementary Benefits Claim Form
INSTRUCTIONS: Plan Administrator: Please print clearly and complete part 1 along with a completed Group Life Plan Sponsor Statement (in the case of accidental
death) or a completed Group Life Benefit Claim form for Accidental Dismemberment or Specific Loss.
Claimant: Please print clearly and complete part 2 & 3 of this form and attach receipts for all eligible expenses along with a completed Group Life Claimant Statement
(in the case of accidental death).
1) EMPLOYEE INFORMATION
2) CLAIMANT INFORMATION
If claimant is a minor child please confirm the name and address of parent or Legal Guardian and the current address for the minor child if different
than above.
3) CLAIM DETAILS
BENEFIT(S) BEING CLAIMED:
(Please check appropriate box)
CHILD EDUCATION BENEFIT
*Attach a photocopy of the child’s birth certificate, original educational documents issued by the school’s registrar confirming full-time enrollment.
FAMILY TRANSPORTATION BENEFIT
* Attach original receipts for eligible transportation, lodging and/or telephone expenses. If a personal vehicle was used, provide a detailed travel log of
kilometres traveled
Do you have Global Medical Assistance insurance with Canada Life? Yes No
SPOUSE OCCUPATIONAL TRAINING BENEFIT
*Please provide an original invoice of expenses from an accredited occupational training program.
EDUCATIONAL BENEFIT FOR EMPLOYEES AND SPOUSES
*Attach original confirmation of enrollment and tuition fees from a post-secondary institution.
WHEELCHAIR BENEFIT
*Attach original invoices detailing expenses for alterations to your residence and/or your personal vehicle.
REPATRIATION BENEFIT
*Attach original invoices for eligible expenses incurred.
With the exception of the spousal retraining benefit and education benefits all expenses for any one benefit must be claimed together.
Claims for subsequent costs for a claim that has already been submitted are not eligible.
Protecting your Privacy
We take your privacy seriously. We keep all your personal information in a confidential file in our offices, or the offices of an organization we’ve authorized.
The only person with access to the information are: people working at Canada Life and those we’ve authorized, who need the information to do their jobs and
manage your claim, those whom you’ve given access, those authorized by law both within Canada and in any other jurisdiction where your personal information is
held. For a copy of our Privacy Guideline see: canadalife.com or you can write to Canada Life’s Chief Compliance Officer.
canadalife.com 1-855-812-4211
M6710-1/20
© The Canada Life Assurance Company, all rights reserved. Canada Life and design are trademarks of The Canada Life Assurance Company.
Any modification of this document without the express written consent of Canada Life is strictly prohibited.
